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THE 
PRACTICE  OF  OBSTETRICS 

EDGAR 


THE 

PRACTICE  OF  OBSTETRICS 

DESIGNED  FOR  THE  USE  OF  STUDENTS 

AND  PRACTITIONERS  OF 

MEDICINE 


J.    CLIFTON    EDGAR 


PROFESSOR    OF    OESTETKICS    AND    CLINICAL    MIDWIFERY    IN    THE    CORNELL    UNIVERSITY    MEDICAL    COLLEGE;     VISITING 

OBSTETRICIAN     TO     THE     EMERGENCY     HOSPITAL     OF     BELLEVUE     HOSPITAL,     NEW    YORK     CITY; 

SURGEON     TO    THE    MANHATTAN    MATERNITY    AND    DISPENSARY;     CONSULTING 

OBSTETRICIAN     TO     THE     NEW    YORK     MATERNITY      HOSPITAL 


THIRD  EDITION,  REVISED 

TWENTY-THIRD  THOUSAND 


mitb  1279  flUustrations,  incluMno  tiv>e  colored 
plates  ant)  38  figures  printed  in  Colors 


PHILADELPHIA 

P.    BLAK  ISTON'S    SON    &    CO 

IOI2   WALNUT   STREET 
I9IO 


Copyright,  1903,  by  P.   Blakiston's  Son  &  Co. 

Copyright,   1904,  by  P.   Blakiston's  Son  &  Co. 

Copyright,   iqo6,  by  P.  Blakiston's  Son  &  Co. 

Reprinted,  1910 


PP.ESS  or 

F.    FELL    COMPANY 
PHILADELPHIA 


TO   THE 

STUDENTS  OF  OBSTETRICS 

OF  THE  PAST  DECADE  AND  A  HALF,  WHOM  IT  HAS  BEEN  MY 
PRIVILEGE  TO  INSTRUCT,  THIS  BOOK  IS 
DEDICATED  BY  THE  AUTHOR 


PREFACE  TO  THE  THIRD  EDITION. 


When  the  first  edition  of  this  book  appeared  three  years  ago,  the  author 
stated  in  the  preface  that  "the  aim  of  the  present  Practice  of  Obstetrics  is  to 
.  present  the  subject  of  midwifery  from  a  practical  and  clinical  standpoint,  so 
that  it  will  best  facilitate  the  requirements  of  the  student  of  medicine  and  of 
the  active  obstetrician."  "To  this  end  the  simplest  classification  has  I  believe 
been  adopted."  This  object  the  author  has  kept  constantly  before  him  in  the 
revisions  for  the  new  editions,  and  how  far  success  has  attended  his  efforts  is  at- 
tested to  by  the  demand  for  ii,ooo  copies  of  the  work  in  less  than  three  years 
from  its  publication. 

The  classification  adopted  in  the  first  edition  has  been  adhered  to  in  the 
subsequent  ones,  as  from  the  experience  of  other  teachers  and  that  of  the 
author  it  has  been  found  generally  satisfactory. 

It  has  been  the  author's  purpose  in  the  third  edition  to  weigh  carefully 
such  criticisms  as  have  appeared,  and  when  possible  to  meet  them. 

The  principal  criticism,  that  the  book  was  too  large,  has  been  answered  by 
reducing  its  size  in  the  present  edition  by  about  one  hundred  pages,  although 
much  new  matter  and  140  new  illustrations  have  been  added.  This  has  been 
accomplished  by  rewriting,  condensing,  the  omission  of  some  now  obsolete 
matter,  and  reducing  the  size  of  some  of  the  illustrations. 

Again,  it  will  be  noted  that  the  classification  is  rendered  more  graphic  by 
the  addition  of  page  numbers  to  the  ten  part  headings  throughout  the  book. 

It  will  be  noted  in  comparing  the  second  and  third  editions  that  the  follow- 
ing new  subjects  have  been  added  to  the  latter,  namely:  i.  Appendicitis  Com- 
plicating Pregnancy.  2.  Tapeworm  Complicating  Pregnancy.  3.  Fibroma  Mol- 
luscum  Gravidarum  (Illustration).  4.  Hematoma  of  the  Vulva  (Illustration). 
5.   Lactation  Atrophy  of  the  Uterus  and  Breasts.      6.   Brachial  Birth  Paralysis. 

7.  Vaginal  Incision  and  Drainage  (Illustration).  8.  New  History  Charts  for 
Institution  Work. 

It  will  be  still  further  noted  that  the  following  subjects  have  been  rewritten 
in  whole  ..or  in  part:  i.  The  Development  of  the  Ovum,  Embryo,  Fetus,  Fetal 
Membranes,  and  Fetal  Structures.  2.  Chorio-epithelioma  Malignum.  3.  The 
Treatment  of  Placenta  Prsevia.  4.  The  Toxemia  of  Pregnancy.  5.  The  Eti- 
ology of  Eclampsia.     6.  Ectopic  Gestation.     7.  Treatment  of  Pelvic  Deformity. 

8.  Morbidity  in  the  Puerperium.  9.  Indications  for  the  Induction  of  Abortion 
and  Premature  Labor.  10.  The  Forceps.  11.  Caesarean  Section.  12.  Vaginal 
Csesarean  Section.  13.  Porro-Caesarean  Section.  14.  Complete  and  Incom- 
plete Abdominal  Hysterectomy. 

From  the  foregoing  changes  it  will  appear  that  much  time  and  work  have 
been  expended  in  the  present  edition  in  bringing  the  embryology  and  pathology 
of  the  subject  up  to  date,  and  that  the  section  on  Obstetric  Surgery  has  been 
largely  rewritten  and  added  to. 


viii  PREFACE  TO,  THE   THIRD  EDITION. 

The  author  still  believes  it  is  inadvisable  in  a  text-book  designed  for  stu- 
dents to  burden  the  text  with  extensive  bibliography  and  history  of  the  various 
subjects  treated;  hence  he  has  introduced  this  matter  only  where  he  has 
deemed  it  advisable. 

The  clinical  material  and  experience  found  in  this  book  were  obtained  by 
the  author  as  Attending  Obstetric  Surgeon  during  the  past  eighteen  years  in 
The  Bellevue  Emergency  Hospital;  The  New  York  Maternity  Hospital;  The 
Midwifery  Dispensary;  The  Society  of  the  Lying-in  Hospital;  The  Mothers' 
and  Babies'  Hospital;  and  The  Manhattan  Maternity  and  Dispensary. 

During  the  above  period  at  least  20,000  cases  of  confinement  have  come 
more  or  less  under  the  personal  observation  of  the  author.  With  two  of  the 
foregoing  institutions  named,  The  Bellevue  Emergency  Hospital  and  The  Man- 
hattan Maternity  and  Dispensary,  the  author  is  still  actively  connected  as  at- 
tending surgeon. 

['$1  For  the  third  time  the  author  desires  to  express  his  thanks  to  the  publishers 
for  their  continued  generosity  and  courtesy, 

J.  Clifton   Edgar. 

50  East  34TH  Street,  New  York  City. 
October  15,  igo6. 


PREFACE  TO  THE  SECOND  EDITION. 


The  exhaustion  of  the  first  edition  of  this  Practice  of  Obstetrics  within  four 
months  of  the  date  of  its  publication,  and  the  many  compUmentary  reviews 
which  have  appeared  and  personal  letters  received  by  the  author,  have  been 
most  gratifying,  and  I  desire  to  express  my  appreciation  of  the  fact  that  my 
efforts  to  present  the  subject  of  obstetrics  from  the  practical  and  clinical  stand- 
point have  not  been  entirely  unsuccessful. 

Too  short  a  time  has  elapsed  since  the  appearance  of  the  first  edition  to 
make  necessary  a  complete  revision  of  the  work. 

1.  Under  Pathological  Pregnancy  will  be  found  a  section  on  "The  Toxemia 
of  Pregnancy,"  and  under  this  latter  subject  I  have  placed,  (i)  Nausea  and 
Vomiting,   (2)  Icterus,  (3)  Convulsions  and  Coma,   (4)  Eclampsia. 

2.  The  section  on  Fever  in  the  Puerperium  in  Part  VIII  of  the  first  edition 
which  included  Puerperal  Sepsis,  has  been  entirely  rewritten  and  brought  up 
to  date  under  the  heading  of  Morbidity  in  the  Puerperium. 

3.  All  the  colored  plates  of  the  first  edition  have  been  remade,  and  three 
new  ones  have  been  added  to  the  second  edition,  namely,  two  of  the  Toxemia 
of  Pregnancy,  and  one  of  the  Stools  of  Healthy  Breast-fed  Infants. 

4.  It  will  be  noticed  that  many  of  the  illustrations  of  the  first  edition  have 
been  redrawn,  and  that  forty-five  new  illustrations  have  been  added  to  the 
second  edition.  Some  typographical  errors  have  been  corrected  and  a  number 
of  minor  changes  made  throughout  the  text. 

5.  I  find  it  necessary  in  the  present  edition  to  restate  my  position  regarding 
the  indications  for  Embryotomy  and  Caesarean  section,  which  from  the  stand 
point  of  laboratory  and  theoretical  obstetrics  were  apparently  misunderstood 
and  therefore  criticized 

I  find  it  unnecessary,  however,  in  the  second  edition  to  change  the  relative 
amount  of  space  devoted  to  Embryotomy  and  Cassarean  section,  namely,  eighteen 
pages  to  the  former  and  eight  to  the  latter;  because  Embryotomy  comprises 
eight  distinct  operations,  many  of  them  complicated,  and  some  of  them  fre- 
quently performed  upon  the  dead  fetus,  while  Cassarean  section,  on  the  other 
hand,  is  a  single  and  simple  operation,  and  not  so  frequently  made  use  of. 

It  is  a  far  cry  in  obstetrics  from  the  theoretical  deductions  of  the  library 
and  the  laboratory  to  the  clinical  conditions  we  find  at  the  bedside. 

The  amount  of  space  devoted  in  the  present  edition  to  the  Toxemia  of  Preg- 
nancy does  not  imply  that  the  existence  of  a  universal  toxic  pregnant  state  is 


X  PREFACE  TO^  THE  SECOND  EDITION. 

yet  established  or  even  fully  believed  in.  The  subject  is  daily  assuming  in- 
creasing importance  and  interest,  and  it  is  to  be  hoped  that  the  physician  will 
study  his  cases  of  pregnancy  with  this  possibility  in  mind,  will  record  and  report 
his  observations,  and  will  especially  give  his  patients  the  benefit  of  any  doubts 
which  may  arise  when  the  question  of  a  toxic  state  is  in  any  way  suggested. 

I  desire  to  express  my  indebtedness  to  James  Ewing,  M.D.,  Professor  of 
Pathology  in  the  Cornell  Medical  College,  for  much  valuable  help  in  the  prepara- 
tion of  the  section  upon  The  Toxemia  of  Pregnancy. 

Again  I  wish  to  thank  the  publishers  for  their  continued  generosity  and 

courtesy. 

J.   Clifton  Edgar. 
50  East  34TH  Street,  New  York  City. 
June  I,  I  go  4. 


PREFACE  TO  THE  FIRST  EDITION. 


This  Practice  of  Obstetrics  is  founded  upon  fifteen  years'  work  in  maternity 
hospitals  and  in  bedside  and  didactic  teaching. 

The  cHnical  and  theoretical  material  collected  from  these  sources  has 
been  rearranged,  rewritten,  and  as  far  as  possible  compared  with  modern 
authorities.  The  aim  of  the  present  Practice  of  Obstetrics  is  to  present  the 
subject  of  midwifery  from  a  practical  and  clinical  standpoint,  so  that  it  will  best 
facilitate  the  requirements  of  the  student  of  medicine  and  of  the  active  obstet- 
rician. To  this  end  the  simplest  classification  has,  I  believe,  been  adopted.  I 
have  omitted  as  unnecessary  in  such  a  work  the  elaborate  section  upon  the 
anatomy  of  the  female  genital  organs  usually  found  in  the  works  upon  obstetrics, 
and  have  entered  directly  upon  the  physiology  of  these  organs.  The  omission 
of  the  separate  section  upon  anatomy  is  to  avoid  repetition,  since  the  anatomy, 
histological  and  topographical,  of  the  pelvis  and  its  contents  will  be  found 
in  its  appropriate  place  under  the  Parts  on  the  Physiology  of  Pregnancy  and 
Labor.  I  have  divided  the  work  into  ten  Parts,  namely:  I.  The  Physiology  of 
the  Female  Genital  Organs.  II.  Physiological  Pregnancy.  III.  Pathological 
Pregnancy.  IV,  Physiological  Labor.  V.  Pathological  Labor.  VI.  Physio- 
logical Puerperium.  VII.  Pathological  Puerperium.  VIII.  The  Physiology  of 
the  Newly  Born.  IX.  The  Pathology  of  the  Newly  Born.  X.  Obstetric 
Surgery. 

This  classification,  elaborated  and  broadened  from  year  to  year,  is  practi- 
cally the  same  that  I  have  followed  during  the  above  period  in  the  two  depart- 
ments of  teaching.     Several  innovations  will  be  found  in  this  book. 

1.  At  the  beginning  of  each  Part  the  table  of  the  contents  of  the  part  in 
question  has  been  placed,  and  to  further  insure  ease  of  reference  each  Part  is 
subdivided  into  sections,  each  section  in  turn  headed  with  a  sub-table  of  its 
subject-matter. 

2.  The  subjects  of  asepsis  and  of  pelvimetry,  including  cephalometry,  are 
treated  under  The  Examination  of  Pregnancy.  I  believe  that  this  is  the  proper 
time  and  place  for  the  student  to  be  drilled  in  these  subjects. 

3.  The  subject  of  Deformities  and  Monstrosities  of  the  Fetus  has  been  entered 
into  more  fully  than  usual  under  Antenatal  Pathology,  with  144  illustrations, 
including  all  of  the  common  and  most  of  the  rarer  monstrosities. 

4.  The  illustrations  of  the  mechanism  of  labor  and  moulding  of  the  fetal 
skull  in  vertex,  bregma,  brow,  face,  and  pelvic  presentation  are  mostly  new, 
and  are  arranged  as  it  has  been  my  custom  to  teach  these  subjects.  The  illus- 
trations of  cervical  engagement  of  the  presenting  part  were  obtained  by  palpating 
with  two  fingers  of  the  left  hand,  and  at  the  same  time  sketching  with  a  soft 
pencil  in  the  right  hand.  Inspection  of  the  cervical  engagement  by  the  aid 
of  a  perineal  retractor  and  reflected  light  was  also  used,  but  this  method  was 
less  satisfactory  than  palpation  except  in  the  case  of  face  presentation.  The 
illustrations  of  vulval  engagement  of  the  presenting  parts  are  from  flash-light 


xii  PREFACE. 

photographs.  Most  of  this  work  was  done  at  the  Emergency  Hospital  of 
Bellevue  Hospital.  The  photographs  of  fetal  skulls  showing  the  result  of 
head  moulding  are  from  skulls  in  the  author's  collection,  which  now  numbers 
over  one  hundred. 

5.  Short  sections  upon  the  medico-legal  aspects  of  obstetrics,  together  with 
a  brief  study  of  Rape,  the  latter  including  an  analysis  of  six  hundred  con- 
secutive examinations  for  evidences  of  the  same,  are  placed  under  their  appro- 
priate Part  headings. 

6.  I  would  especially  call  attention  to  the  following  subjects:  (i)  The  relation 
of  tuberculosis  to  pregnancy.  (2)  The  teeth  in  pregnancy.  (3)  Antenatal  path- 
ology. (4)  Monstrosities,  and  deformities  of  the  fetus.  (5)  Labor  in  elderly 
primiparse.  (6)  Prophylactic  diet  in  fetal  dystocia.  (7)  Prematurity  and  asphyxia 
of  the  newly  born.  (8)  The  diseases  of  the  newly  born.  (9)  Posture  in  ob- 
stetrics, and  Obstetric  Surgery.  (10)  The  complete  presentation  of  the  subject 
of  cephalometry.  (11)  New  method  for  illustrating  the  mechanism  of  labor. 
(12)  Pelvic  Deformity.  (13)  Morbidity  in  the  Puerperium.  (14)  An  appendix 
on  obstetric  history  keeping. 

Radiography  in  obstetrical  practice  is  still  in  its  infancy  and  the  results  as 
to  fetography  have  been  disappointing.  On  the  other  hand,  Rontgen  pho- 
tography of  the  maternal  pelvis  is  a  highly  promising  field,  but  as  yet  offers  no 
practical  advantages. 

As  far  as  possible  the  subject  of  Embryology  has  been  considered  from  the 
practical  and  clinical  standpoint,  and  detail  has  been  omitted  as  not  suited  to 
a  work  on  practical  obstetrics.  Anatomical  descriptions,  except  as  necessary 
for  the  subjects  of  pregnancy  and  labor,  have  also  been  omitted. 

Much  work  had  been  expended  upon  the  section  on  antenatal  diseases  of 
the  fetus,  before  the  appearance  of  Dr.  Ballantyne's  pioneer  book  upon  Ante- 
natal Pathology.  This  work  I  have  freely  consulted  in  the  revision  of  my 
manuscript. 

The  2200  confinement  cases  from  which  many  of  my  statistics  are  drawn 
comprise  1000  cases  from  the  New  York  Maternity  Hospital  and  1200  from  the 
Mothers'  and  Babies'  Hospital;  800  of  the  latter  being  dispensary  or  outdoor 
cases.  The  bound  histories  of  these  cases  have  been  presented  to  the  New 
York  Academy  of  Medicine,  and  are  there  available  for  inspection. 

All  unnecessary  division  into  chapters  has  been  discarded,  and  as  far  as 
possible  italicizing  has  also  been  avoided.  To  replace  the  latter  a  system  of 
paragraphing  by  means  of  display  type  in  four  series  has  been  uniformly  adopted 
throughout,  supplemented  by  numerical  divisions.  It  will  be  observed  that  as 
far  as  possible  full-page  illustrations  have  been  avoided.  My  aim  has  been  to 
insert  the  illustrations  in  the  midst  of  the  text  itself  so  as  to  more  readily  catch 
the  eye  of  the  reader.  To  this  end  a  rather  wider  page  of  printed  matter  than 
usual  has  been  made  use  of  and  the  illustrations  are  of  moderate  size.  Many 
of  the  illustrations  are  new,  collected  during  fifteen  years  of  clinical  work,  and 
most  of  those  taken  from  other  sources  have  been  redrawn. 

The  illustrations,  as  will  be  noted,  are  not  reproduced  to  a  given  scale,  as  I 
have  found  that  clearness  of  detail  is  best  obtained  by  the  use  of  different  scales 
of  reproduction.  All  weights  and  measurements  are  given  in  English,  with  the 
metric  system  equivalents  in  parenthesis. 

To  Simon  Henry  Gage,  B.S.,  Professor  of  Histology  and  Embryology  in  the 
Cornell  University,  I  am  indebted  for  his  critical  revision  of  my  manuscript  on 
"The  Phenomena  Produced  by  Pregnancy  within  the  Uterus."  Also  to  Drs. 
Edward  Preble  and  Emma  E.  Walker  for  much  valuable  assistance  in  the  search 


PREFACE.  xiii 

through  recent  foreign  obstetric  literature  and  in  the  preparation  of  the  index. 
The  drawings  for  the  illustrations  were  executed  by  Frank  Stout,  Howard  J. 
Shannon,  Frederick  A.  Fulton,  and  H.  C.  Lehmann. 

The  author  desires  to  thank  most  cordially  the  successive  members  of  the 
House  Staffs  of  the  New  York  Maternity  Hospital,  and  Emergency  Hospitals, 
for  valuable  assistance  in  the  preparation  of  the  histories  and  records  of 
obstetric  cases;  also  Mr.  Kenneth  M.  Blakiston,  of  the  pubhshing  firm  of 
Messrs.  P.  Blakiston's  Son  &  Co.,  for  his  unfailing  courtesy  in  the  many 
details  of  the  preparation  of  the  illustrations  and  the  publication  of  the  work. 

J.  Clifton  Edgar. 
50  East  34TH  Street,   New  York  City, 
yune  15,   I  go  3. 


TABLE  OF  CONTENTS. 


PART  I. 

PAGE 

THE  PHYSIOLOGY  OF  THE  FEMALE  GENITAL  ORGANS,  i6 
This  Part  Contains  37  Illustrations. 

SECTION 

I.  Ovulation, 1 7-19 

II.  Menstruation,    20-26 

III.  Insemination, 26 

IV.  Impregnation,  . 27-29 

V.  Rape, 29-34 

VI.  Hygiene  of  the  Sexual  Functions, 35-39 


PART  IL 
PHYSIOLOGICAL  PREGNANCY, 41 

This  Part  Contains  192  Illustrations. 

I.  Phenomena  Produced  by  Pregnancy  within  the  Uterus 41-  88 

II.  Phenomena  Produced  by  Pregnancy  in  the  Maternal  Organism, 89-118 

III.  The  Diagnosis  of  Pregnancy 1 19-132 

IV.  The  Differential  Diagnosis  of  Pregnancy,  132-138 

V.  Feigned  Pregnancy — Pseudocyesis,   138-139 

VI.  Unconscious  Pregnancy 139 

VII.  Multiple  Pregnancy 140-144 

VIII.  The  Duration  op  Pregnancy 144-145 

IX.  Calculating  the  Date  of  Confinement 146-14S 

X.  The  Examination  of  Pregnancy, 14S-184 

XL  The  Hygiene  and  Management  of  Pregnancy, 184-188 


PART  III. 
PATHOLOGICAL  PREGNANCY, 1S9 

This  Part  Contains  276  Illustrations. 

I.  Diseases  of  the  Decidu^, 101-198 

II.  Diseases  of  the  Chorion, 198-201 

III.  Anomalies  of  the  Amnion  and  Liquor  Amnii, 201  -208 

XV 


xvi  TABLE   OF  CONTENTS. 

SECTION  PAGE 

IV.  Anomalies  and  Diseases  of  the  Placenta, 208-237 

V.  Anomalies  of  the  Umbilical  Cord 237-242 

VI.  Deformities  and  Monstrosities  of  the  Fetus, 244-254 

VII.  Antenatal  Diseases  of  the  Fetus .255-271 

VIII.  Death  of  the  Fetus, 272-274 

IX.  Diseases  of  the  Genital  Organs, 274-291 

X.  Toxemia  of  Pregnancy, 291-314 

XI.  Diseases  of  the  Urinary  Tract 315-321 

XII.  Diseases  of  the  Alimentary  Tract, 321-325 

XIII.  Diseases  of  the  Circulatory  System, 325-328 

XIV.  Diseases  of  the  Respiratory  System, 329-332 

XV.  Diseases  of  the  Nervous  System 332-33S 

XVI.  Infectious  Diseases :i3^-337 

XVII.  Skin  Diseases 337-34° 

XVIII.  Diseases  of  the  Osseous  System : 340-342 

XIX.  The  Premature  Interruption  of  Pregnancy 342-361 

XX.  Ectopic  Gestation, 361-367 

XXI.  Pregnancy  in  One  Horn  of  a  Uterus;  Unicornis  or  Bicornis 367-368 

XXII-  Missed    Labor, 3^8 

XXIII.  Sudden  Death  During  Pregnancy, 369 

XXIV.  Injuries  and  Operations  upon  Pregnant  Women, 369-37° 

XXV.  Pregnancy  after  Operations  Involving  the  Genitals 370 

XXVI.  The  Fever  of  Pregnancy, 370 

XXVII.  The  Metrorrhagia  of  Pregnancy 3  7^-372 


PART  IV. 
PHYSIOLOGICAL  LABOR, 373 

This  Part  Contains  132  Illustrations. 

I.  The  Passages, 375-408 

II.  The  Fetus 408-427 

III.  Expelling  Forces,   428-431 

IV.  Etiology  of  Labor, 431 

V.  The  Stages  of  Labor 432-440 

VI.  The  Mechanism  of  Labor, 440-448 

VII.  The  Duration  of  Labor 448 

VIII.  Live  Birth 448 

IX.  Feigned  Delivery, 449 

X.  Unconscious  Delivery, , 449-450 

XI.  Vertex  Presentation, 450-463 

XII.  Management  of  Labor 463-496 


PART  V. 

* 

PATHOLOGICAL  LABOR, 499 

This  Part  Contains  269  Illustrations. 

DUE  TO  ABNORMAL   CONDITIONS  OF  THE  FETUS:  FETAL  DYSTOCIA, 499 

Fetal  Dystocia  from  Faulty  Attitude, 499 

I.  Excessive  Flexion  of  the  Head,  Roederer's  Obliquity, 499-500 


TABLE  OF  CONTENTS.  xvii 

SECTION  PAGE 

II.   Bregma  Presentation.  .    Incomplete  Flexion 500-503 

III.  Brow  Presentation, 503-508 

IV.  Face  Presentation, 508-5 1 8 

V.  Presentation  of  Anterior  Parietal  Bone  or  Ear.     Naegele's  Obli- 
quity   518 

VI.  Presentation   of   Posterior  Parietal   Bone   or   Ear.       Litzmann's 

Obliquity, 5  ig 

VII.  Prolapse  of  the  Arms.     Dorsal  Displacement  of  the  Arm 520-522 

VIII.  Prolapse  of  the  Legs 522 

IX.  Prolapse  of  the  Cord, 522-527 

Fetal  Dystocia  from  Faulty  Presentation, 527 

X.  Pelvic  Presentation 527-538 

XI.  Shoulder  Presentation, 538-544 

Fetal  Dystocia  from  Faulty  Position, 545 

XII.  Persistent  Occipito-posterior  Position 545-550 

XIII.  Persistent  Mento-posterior  Position 550-553 

XIV.  Transverse  Position  of  Head  at  Outlet, 553-554 

Fetal  Dystocia  from  General  Fetal  Conditions, 554 

XV.  Multiple  Birth 554-557 

XVI.  Multiple  or  Compound  Presentations, 558-559 

XVII.  Excessively  Long  Cord 559 

XVIII.  Short  Cord 559-560 

XIX.  Rupture  of  the  Cord 560 

XX.  Decapitation  of  the  Fetus 560 

XXI.  Avulsion  of  Fetal  Extremities 560 

XXII.  Malformations,  Deformities,  and  Anomalies  Producing  Dystocia,.  .  .560-565 
XXIII.  Fetal  Rigor  Mortis 565 

DUE    TO  ABNORMAL  CONDITIONS    OF   THE   MOTHER.     MATERNAL    DYS- 
TOCIA,    566 

Maternal  Dystocia  from  the  Forces, 567 

I.  Precipitate  '  Labor, 567-568 

II.  Protracted  OR  Retarded  Labor:     Uterine  and  Abdominal  Inertia,  .568-574 
Maternal  Dystocia  in  the  Parturient  Tract  and  Adnexa, 574 

III.  Retention  of  Placenta  and  Membranes 574-577 

IV.  PosT-PARTUM   Hemorrhage 577-584 

V.  Rupture  of  the  Uterus, 584-590 

VI.  Inversion  of  the  Uterus, 590-592 

VII.  Excessive  Right  Lateral  Obliquity  of  the  Uterus 592 

VIII.  Rupture  of  Cervix,  Vagina,   Rectum,  Perineum 592-600 

IX.  Labor  After  Anterior  Fixation  or  Suspension  of  the  Uterus, 600-602 

Maternal  Dystocia  from  Obstructed  Labor, 602 

X.  Uterine,  Ovarian,  Renal,  Peritoneal  Tumors, 602-605 

XI.  Anomalies  of  the  Membranes 605 

XII.  Rigidity  of  the  External  and  Internal  Os.     Trismus  Uteri 606-608 

XIII.  Deviation  or  Malposition  of  the  Os, 608-609 

XIV.  Occlusion  of  the  External  Os 609 

XV.  Cancer  of  the  Uterus, 610 

XVI.  Rigidity  and  Atresia  of  the  Vagina  and  Vulva, 610-612 

XVII.  Vaginal  and  Vulval  Thrombosis  and  CEdema, 613 

XVIII.  Distended  Bladder   and    Rectum,  Cystocele,   Rectocele,  Vesical 

Calculus, 613-615 

XIX.  Fractures  of  the  Pelvis 615 

XX.  Diastasis  of  the  Pelvic  Joints, 615 

XXI.  Pelvic  Deformity 616-665 


xviii  TABLE   OF   CONTENTS. 

SECTION  PAGE 

Maternal  Dystocia  from  General  Maternal  Conditions, 665 

XXII.  Labor  in  Elderly  Primipar^ 665-667 

XXIII.  Intestinal  Hernia 667 

XXIV.  Cardiac  and  Pulmonary  Disease, 668 

XXV.  Cerebral  and  Spinal  Disease 668 

XXVI.  Digestive  Disturbances 669 

XXVII.  Sudden  Death, 669 

XXVIII.  Postmortem  Delivery, 669-670 

XXIX.  The  Metrorrhagia  of  Labor, 671 


PART  VI. 
PHYSIOLOGICAL  PUERPERIUM.  THE  PUERPERAL  WOMAN,         672 

This  Part  Contains  18  Illustrations. 

I.  General  Phenomena, 672-677 

II.  Local   Phenomena, 677-687 

III.  Diagnosis  of  the  Puerperium,   687-688 

IV.  Management  of  the  Puerperium, 688-698 


PART  VII. 
PATHOLOGICAL  PUERPERIUM, 700 

This  Part  Contains  54  Illustrations. 

I.  Puerperal  Hemorrhages 701-705 

II.  Intestinal  Anomalies 705 

III.  Urinary  Anomalies, ' 705-707 

IV.  Anomalies  of  the  Genital  Tract, 708-7 10 

V.  Anomalies  of  the  Pelvic  Articulations 710 

VI.  Diastasis  of  the  Abdominal  Muscles 711 

VII.  Fever  in  the  Puerperium, 71 1-758 

VIII.  Anomalies  of  the  Breasts, 759-760 

IX.  Anomalies  of  the  Milk  Secretion, 760-761 

X.  Diseases  of  the  Breasts 761-768 

XI.  Blood  Conditions,   768-769 

XII.  Diseases  of  the  Nervous  System,   769-773 

XIII.  Skin  Diseases, 773 

XIV.  General    Diseases, 773 

XV.  Sudden  Death, 773-776 


PART  VIII. 
THE  PHYSIOLOGY  OF  THE  NEWLY  BORN, 778 

This  Part  Contains  19  Illustrations. 

I.  General  Phenomena 779-7S5 

II.  Hygiene  and  Management  of  the  Newly  Born, 785-796 


TABLE  OF  CONTENTS.  xix 

PART  IX. 

PAGE 

THE  PATHOLOGY  OF  THE  NEWLY  BORN, 798 

This  Part  Contains  37  Illustrations. 

SECTION 

I.   Pathology  due  to  Interrupted  Pregnancy.     Prematurity, 800-807 

II.  Affections  of  Antenatal  Origin  which   Extend  into  Extrauterine 

Life, 807-812 

III.  Affections  which  Originate  Intra  partum, 812-837 

IV.  Diseases  Incident  to  Change  of  Environment 837-840 

V.  Diseases  due  to  Bacteria  and  Fungi, 840-847 

VI.  Diseases  of  Unknown  Nature, 847-S51 

VII.  General  Post-partum  Conditions, •. 852-856 


PART  X. 
OBSTETRIC  SURGERY, 858 

This  Part  Contains  239  Illustrations. 

(A)  INTRODUCTION, S59 

I.  Preparations  for  Operation, 860-86 1 

II.  Decinormal  Saline  Solution  Injections, 86 1-S65 

III.  Anesthesia  in  Obstetrics, S65-S68 

IV.  Posture  in  Obstetrics, 868-879 

V.  Vaginal  Examination 879 

VI.  Digital  Exploration  of  the  Uterus, S80 

VII.  Vulval  Douche, S81 

VIII.  Vaginal  Douche, S81-882 

IX.  Intrauterine  Douche 882-S84 

X.  Vaginal  Tampon S84-S85 

XI.  Uterine  Tampon, 885-887 

XII.  Passing  the  Catheter 887 

(B)  OPERATIONS  PREPARATORY  TO  DELIVERY, 887 

I.  Artificial  Rupture  of  the  Membranes, 887-888 

II.  Induction  of  Abortion  and  Premature  Labor, 888-895 

III.  Manual  Dilatation  of  the  Cervix, 895-901 

IV.  Instrumental  Dilatation  of  the  Cervix 902-906 

V.  Manual  and  Instrumental  Dilatation  of  the  Vagina  and  Vulva, 906-907 

VI.  Incisions  of  the  Cervix,  Vagina,  and  Vulva 907-91 1 

VII.  Correction   of   Faulty  Postures,   Malpositions,  and   Malpresenta- 

TioNS 911-914 

VIII.  Vectis 915 

IX.  Fillet, 915-916 

X.  Reposition  of  Prolapsed  Small  Parts,  Foot,  and  Cord, 916-9 19 

XI.  Version 919-936 

XII.  Pelviotomy, 936 

XIII.  Symphyseotomy,   937-942 

XIV.  Embryotomy  in  General, ^-  942-944 

XV.  Perforation 944-946 

XVI.  Rachidotomy,    946 

XVII.  Cranioclasm, 947-951 

XVIII.  Cephalotripsy 951-955 


XX  TABLE   OF  CONTENTS. 

SECTION  PAGE 

XIX.  Decapitation 955-960 

XX,  Evisceration,    960-961 

XXI,  Amputation  of  Extremities 961 

XXII.  Cleidotomy 961-962 

XXIII.  Spondylotomy 963 

(C)  OPERATIONS  FOR  DELIVERY, 963 

I.  Expression  of  the  Fetus,  Expressio  Fcetus, 963-964 

II.  Forcible  Delivery,  Accouchement  Force, 964-965 

III.  Manual  Extraction  of  the  Fore-coming  Head, 965 

IV.  Shoulder  Extraction  in  Head-first  Labors, 966-968 

V.  Breech  Extraction, 968-973 

VI,  Extraction  of  the  After-coming  Head 974-982 

VII.  Forceps 982-1007 

VIII.  Sling  or  Soft  Fillet 1007-1009 

IX.  Blunt  Hook, 1009-1010 

X.  Crochet,   10 10 

XI.  Extraction  of  the  Fetus  Mutilated  by  Embryotomy, loii 

XII.  CjESarean  Section 1011-1016 

XIII.  Abdominal  Hysterectomy, 1016-1020 

XIV.  Porro-C.«;sarean  Section 1020-1022 

XV,  Vaginal  Cesarean  Section, 1022-1025 

XVI.  Post-mortem  Cesarean  Section, 1025 

XVII.  Delivery  of  Placenta  and  Membranes 102  5-103 1 

(D)  OPERATIONS  FOR  THE  CORRECTION   OF   INJURIES, 103 1 

I.  Celiotomy  for  Rupture  of  the  Uterus, 1032 

II.  Celiotomy  for  Sepsis  of  the  Uterus, 1032 

III.  Repair  of  Injuries  to  Cervix,  Vagina,  Rectum,  Perineum, 1032-1037 


APPENDIX. 

This  Contains  10  Illustrations. 

Private  History  Records 1039-1042 

Institutional  Records 1043-1046 


INDEX '  I047 


\ 


PART    ONE. 

The  Physiology  of  the  Female  Genital  Organs* 


I.  OVULATION.  (Page  17.)  Definition ;  Origin  of  the  Ova ;  Causes  of  Rup- 
ture of  the  Graafian  Follicle ;  Mechanism  of  the  Conveyance  of  the  Ovum  to 
the  Tubes  and  Uterus ;  Corpus  Luteum ;  Retrograde  Changes  in  the  Corpus 
Luteum ;  Obliteration  of  Follicles  which  do  not  Rupture. 

II.  MENSTRUATION.  (Page  20.)  Synonyms;  Definition;  Puberty;  Pheno- 
mena ;  Changes  in  the  Endometrium  during  Menstruation ;  Time  of  Occur- 
rence; Conditions  Influencing  Menstruation;  The  Menstrual  Cycle;  Men- 
struation— Temporary,  Intermittent,  and  Periodic;  Duration;  Quantity  of 
Blood  Lost ;  Composition  of  the  Menstrual  Blood ;  Modifications  and  Ano- 
malies ;  Relation  between  Menstruation  and  Ovulation ;  The  Menopause. 

III.  INSEMINATION.     (Page  27.)     Definition;  Phenomena. 

IV.  IMPREGNATION.     (Page   27.)     Synonyms;  Definition;  The  Semen;    The 

Spermatozoa ;  Ascent  of  the  Spermatozoa ;  Place  of  Meeting  of  Spermatozoa 
and  Ovum;  Relation  between  Impregnation  and  Menstruation;  Unconscious 
Impregnation. 

V.  RAPE.  (Page  29.)  Definition  ;  Law  of  Rape ;  Rape  on  Females  after  Pub- 
erty; Conditions  Simulating  Defloration;  Rape  upon  Children  and  Infants; 
Rape  by  Boys  and  Children ;  Rape  on  the  Dead ;  Statistics  of  600  Consecu- 
tive Examinations  for  Evidences  of  Rape. 

VI.  HYGIENE  OF  THE  SEXUAL  FUNCTIONS.  (Page  35.)  Heredity;  Educa- 
tion ;  Mode  of  Life ;  Dress ;  Sexual  Life ;  Prevention  of  Conception  ;  Child- 
birth ;  Climacteric ;  Cancer ;  Family  Physician. 


I.  OVULATION. 

Definition. — -This  term  includes  the  formation,  growth,  and  expulsion  of  the 
mature  ovum  from  the  ovary.  The  chief  function  of  the  ovary  is  accomplished  in 
this  process.     It  takes  place  spontaneously  in  all  viviparous  animals. 

Origin  of  the  Ova. — The  ova  originate  from  certain  cells  which  are  derived 
from  the  ingrowth  of  the  germinal  epithelium  that  surrounds  the  young  ovary, 
and  which  are  gradually  differentiated  into  the  female  generative  elements. 
This  occurs  very  early;  in  fact,  the  formation  of  the  Graafian  follicles  is  nearly 
completed  during  the  antenatal  period.  After  birth  the  formation  of  new  cells 
is  much  restricted,  and  at  the  end  of  the  second  year  is  supposed  to  cease  entirely. 
The  ovaries  of  a  child  of  two  years  are  estimated  to  contain  about  70,000  Graafian 
follicles.  The  greater  number  of  ova  never  arrive  at  maturity.  Before  puberty 
some  of  these  immature  ova  undoubtedly  develop  to  a  certain  point,  but  it  is  not 
until  the  establishment  of  menstruation  that  the  normally  complete  maturation 
of  the  follicles  with  their  ova  takes  place.  With  the  advent  of  puberty  the  sur- 
face of  the  ovary  becomes  covered  with  small  projections.  These  prominences 
are  the  Graafian  follicles,  which  are  distended  by  the  liquid  within  them.  They 
approach  the  ovarian  periphery,  cause  a  thinning  of  the  tunica  albuginea,  and 
give  rise  to  the  vesicles  before  mentioned.  Gradually  the  blood-vessels  and 
lymphatics  disappear,  and  at  a  certain  point  the  covering  of  the  follicles  becomes 
thin  and  translucent,  usually  at  the  place  called  the  macula,  or  stigma  folliculi. 
When  the  follicle  reaches  maturity  it  bursts,  discharging  its  contents,  which 
consist  of  an  ovum,  the  liquor  folliculi,  and  a  few  cells  of  the  discus  proligerus. 
This  change  takes  place  periodically,  now  in  one,  now  in  more  than  one  follicle, 
during  the  entire  child-bearing  period.  Several  follicles  in  different  stages  of 
development  may  be  found  at  the  same  time.  The  particular  follicle  that  is 
nearing  maturity  becomes  congested  and  some  of  the  enlarged  blood-vessels 
burst  into  its  cavity,  thus  increasing  the  distention  and  the  tendency  to  rupture. 
When  mature,  the  follicle  is,  on  account  of  the  escaped  blood,  of  a  bright  red 
color.  As  to  the  time  of  rupture  of  the  follicle,  whether  it  occurs  before  or  after 
menstruation,  is  a  question  not  yet  definitely  settled.  In  order  that  the  ovule 
may  escape,  not  only  must  the  layers  of  the  follicle  be  lacerated  but  also  all  of 
the  structures  covering  it. 

Causes  of  Rupture  of  the  Graafian  Follicle. — Follicular  rupture  is  produced  by 
a  combination  of  several  factors:  (i)  By  the  pressure  of  the  liquor  folliculi,  which 
causes  thinning  and  absorption  of  the  theca  folliculi,  the  follicular  wall  having 
been  weakened  by  fatty  degeneration  of  the  tissues.  (2)  B}^  the  proliferation  of 
the  lutein  cells,  causing  the  tension  of  the  liquor  to  be  raised.  (3)  By  the  swell- 
ing of  the  ovary  at  every  menstrual  period.  (4)  By  the  contraction  of  the 
ovarian  muscular  fibers.  (5)  Ovulation  is  a  periodic  process,  and  in  nearly  all 
mammals,  except  man,  it  occurs  only  at  certain  seasons  of  the  year,  so  that 
the  young  are  born  at  a  time  when  food  suitable  for  the  parent  is  most  abundant. 
(6)  Sexual  congress  may  influence  the  discharge  of  the  ovum,  probably  only 
hastening  the  normal  process.  (7)  The  sympathetic  nervous  S3'-stem  also  in 
some  way  affects  the  process. 

2  17 


IS  PHYSIOLOGY  OF  THE  FEMALE  GENITAL  ORGANS. 

Mechanism  of  the  Conveyance  of  the  Ovum  to  the  Tubes  and  Uterus. — The 

oldest  theory  of  this  conveyance,  that  held  by  Rouget,  was  that  the  fimbriated 
extremity  of  the  tube  became  erectile  and,  aided  by  muscular  contraction, 
grasped  the  ovary.  The  existence  of  a  peculiar  erectility  in  the  Fallopian 
tubes  has,  however,  been  disproved,  as  experiments  show  that  it  possesses  none 
of  the  characteristics  of  erectile  tissue.  Galvanization  of  the  tubes  shortly  after 
death  produces  only  a  vermicular  action  which  has  no  effect  on  the  position  of 
the  fimbriae.  Kehrer's  theory  was  that  the  ova  were  ejaculated  from  the  follicle 
into  the  tube,  a  view  that  has  been  upheld  by  few.  The  most  probable  theory  is 
that  of  Henle,  that  the  ova  are  carried  along  in  the  serum  by  currents  generated 
by  the  ciliated  epithelium  which  covers  the  fimbriae  of  the  tubes.  This  ciliary 
motion  causes  a  current  in  Douglas'  cul-de-sac.  This  action  has  been  demon- 
strated by  Pinner,  who  injected  powdered  insoluble  coloring-matter  into  the 
abdominal  cavity  of  a  rabbit.  Particles  were  found  after  death  in  the  uterus  and 
vagina.  The  same  phenomenon  was  observed  by  Jani  (W^igert's  laboratory)  in 
regard  to  tubercle  bacilli.  Lodi  injected  the  eggs  of  a  tapeworm  into  the  peri- 
toneal cavity  of  rabbits  and  recovered  them  in  the  tubes  and  uterus.  In  the 
lower  animals  the  majority  of  the  ova  pass  into  the  tube,  but  in  man  it  would 
seem  that  the  greater  part  are  thrown  into  the  abdominal  cavity.  It  is  usually 
stated  that  it  takes  eight  days  for  the  ova  to  reach  the  uterus.  In  a  certain 
number  of  cases  there  is  a  migration  of  ova,  which  pass  across  the  abdominal 
cavity  and  come  down  the  opposite  tube.  This  is  called  external  migration. 
Pathological  conditions  afford  proof  of  this  fact.  There  are  two  classes  of  such 
cases:  (i)  With  normal  tubes.  If  we  find  a  corpus  luteum  in  the  right  ovary 
and  the  right  tube  converted  into  a  hydrosalpinx,  the  inference  of  external  migra- 
tion may  be  drawn.  Also  in  tubal  pregnancy:  given  an  occluded  right  tube 
with  a  corpus  luteum  in  the  right  ovary,  and  a  pregnancy  in  the  left  tube  with  no 
•corpus  luteum  in  the  left  ovary,  and  we  must  draw  the  same  inference.  (2)  In 
the  case  of  bicornate  uterus  a  corpus  luteum  may  be  found  in  one  ovary  and 
pregnancy  in  the  other  side  of  the  uterus.  Kussmaul  was  the  first  to  advocate 
this  view  of  external  migration.  Leopold  and  others  have  experimented  by 
removing  in  an  animal  a  tube  and  the  opposite  ovary.  Later,  if  the  animal 
became  pregnant  the  proof  of  external  migration  was  positive.  I  have  re- 
peatedly demonstrated  this  external  migration  of  the  ovum  by  operating  upon 
rabbits  in  the  Loomis  Laboratory.  Older  writers  declared  that  there  was  internal 
migration  causing  tubal  pregnancy  in  the  opposite  tube,  the  ovum  having  passed 
through  the  uterus.  This  statement  cannot  be  denied,  neither  can  it  be  proved. 
Hence  we  see  that  external  migration  does  take  place,  whereas  the  occurrence 
of  internal,  though  possible,  has  not  been  proved. 

Corpus  Luteum. — After  the  follicle  has  ruptured  and  the  ovum  has  been  cast 
off,  the  corpus  luteum  is  formed.  As  has  been  said,  previous  to  rupture  there  has 
occurred  a  fatt}^  degeneration  of  the  cells  of  the  membrana  granulosa  and  of  the 
discus  proligerus.  There  is  a  certain  amount  of  hemorrhage  within  the  follicle,  the 
walls  collapse,  and  this  is  the  first  stage  of  the  corpus  luteum.  The  hematin  of  the 
extravasated  blood  gives  rise  to  the  "yellow"  color.  The  cells  of  the  internal 
layer  of  the  theca  folliculi  rapidly  proliferate,  forming  festoons  which  project  into 
the  blood-clot  contained  in  the  cavity  of  the  folHcle  (Fig.  i).  This  yellow  layer  is 
quite  thick,  being  about  one-half  the  thickness  of  the  whole  corpus,  which  meas- 
ures half  an  inch  (1.25  cm.).  These  cells  are  lutein  cells.  The  stroma  of  the  ovary 
also  sends  ingrowths  into  this  mass.  The  blood-clot  organizes,  the  walls  contract, 
and  finally  a  small,  irregular  cavity  is  left.  This  is  at  last  obliterated  by  the 
meeting  of  the  walls,  and  merely  a  cleft  remains.     A  corpus  luteum  is  formed 


OVULATION. 


19 


with  every  bursting  of  a  follicle.  When  fertilization  of  the  ovum  occurs,  the 
corpus  luteum  becomes  larger.  ■  The  old  terminology  recognizes  a  corpus  luteum 
verum  and  a  corpus  luteum  spurium.  The  corpus  luteum  of  pregnancy  meas- 
ures from  about  four-fifths  to  one  inch  (2  to  2.5  cm.)  in  diameter,  while  the 
ordinary  corpus  luteum  measures  about  three- fifths  inch  (1.5  cm.).  For  some 
time  the  idea  obtained  that  there  was  a  marked  difference  between  the  corpus 
luteum  verum  and  the  corpus  luteum  spurium;  it  has,  however, been  shown  that 
the  only  difference  is  that  of  size,  due  to  the  greater  blood-supply  during  preg- 
nancy. There  has  been  endless  discussion  about  the  corpus  luteum,  the  principal 
point  of  dispute  being  the  hyaline  change. 

Retrograde  Changes  in  the  Corpus  Luteum. — After  the  formation  of  the  corpus 
luteum  the  yellow  layer  is  converted  into  a  hyaline  mass  which  is  penetrated  by  a 


Tunica  externa 
Tunica  interna 


Stratum  granulo- 
sum  (follicular 
epithelium) 


Cumulus  ovigerus 


Ovum  with  zona 
pellucida,  germi- 
nal vesicle,  and 
germinal  spot 


Fig.  I. — Section  of  a  Large  Graafian  Follicle  of  a  Child  Eight  Years  Old.     X  9°- 
The  clear  space  within  the  follicle  contains  the  liquor  follictdi. — (Stohr.) 


few  bands  of  ovarian  stroma.  Finally  a  thin  layer  of  connective  tissue  is  the  only 
representative  of  the  blood-clot,  and  this  stage  is  known  as  the  corpus  fibrosum 
or  corpus  albicans.  But  still  further  changes  must  go  on,  for  only  a  few  of  these 
bodies  are  to  be  found  in  an  ovary.  The  minor  details  of  these  changes  are  not 
well  known.  The  ovarian  stroma  prolongations  increase,  while  the  hyahne 
material  diminishes  and  assumes  bizarre  forms.  At  last  there  may  be  only  a 
trace  of  connective  tissue  remaining.  Only  twenty  or  thirty  folhcles  rupture  in 
a  year  and  many  ova  disappear.     Many  folhcles  never  rupture  at  all. 

Obliteration  of  Follicles  which  do  not  Rupture. — The  ovum  may  assume  signs 
of  maturity,  fatty  degeneration  takes  place  in  the  membrana  granulosa,  the 
whole  mass  dissolves  in  the  hquor  follicuH,  and  the  fluid  finally  disappears  and 
the  walls  collapse.  There  is  absence  of  blood-clot.  The  foUicle  is  surrounded  by 
a  thin  hyaline  stratum  formed  from  the  inner  layer  of  the  theca  foUiculi. 


20 


PHYSIOLOGY  OF   THE  FEMALE  GENITAL  ORGANS. 


II.  MENSTRUATION. 

Synonyms. — Menses;  Menstrual  flow;  Menstrual  flux;  Flow;  Catamenia. 

Definition. — By  menstruation  is  meant  the  monthly  hemorrhage  which  takes 
place  in  the  uterus  during  the  child-bearing  period  of  the  normal  woman,  except 
during  pregnancy  and  lactation,  when  it  is  nearly  always  suspended. 

Puberty. — The  first  occurrence  of  menstruation  with  the  accompanying 
changes  marks  the  stage  of  sexual  maturity  at  which,  in  the  female,  fecundation 
becomes  possible.  The  signs  are:  The  growth  of  hair  on  the  pubes  and  on  other 
parts  of  the  body;  the  enlargement  of  the  breasts;  the  increased  grace  of  the 
general  contour  of  the  body ;  the  establishment  of  ovulation  and  menstruation ; 
the  full  development  of  the  pelvis;  the  growth  of  the  sexual  sense;  alteration  in. 


Fig.   2. — Uterus   and  Adnexa   showing   Coincident   Menstruation   and   Ovulation. 
Suicidal  death  from  morphine  on  second  day  of  menstruation. — (Author's  specimen.) 


the  mental  qualities,  the  girl  becoming  more  retiring.  The  menstrual  function 
is  not  generally  established  at  once,  but  for  the  first  few  months  there  may  be  only 
premonitory  symptoms  of  a  vague  and  uncomfortable  nature.  There  may  soon 
occur  a  slight  discharge  of  mucus  tinged  with  blood,  and  later  the  regular  menses 
will  be  established. 

Phenomena. — (i)  The  General  Phenomena  consist  of  pains  in  various  parts 
of  the  body,  chilliness,  heat  flashes,  and  hysterical  symptoms.  The  reflex 
nervous  system  is  always  at  its  maximum  point  of  irritability  and  there  is  often 
depression  with  drowsiness.  There  are  general  discomfort,  weariness,  and  a 
marked  distaste  for  active  exercise.  Dark  circles  appear  under  the  eyes,  the 
breasts  swell  and  become  painful,  and  a  sense  of  fulness  and  oppression  is  felt  in 
the  head  (Fig.  6).  There  are  often  considerable  changes  in  the  general  nutritive 
processes  and  the  excretion  of  urea  by  the  kidneys  is  lessened.  (2)  The  Local 
Phenomena  are  those  of  pelvic  congestion.     Rupture  of  an  ovisac  occurs,  the 


MENSTRUATION. 


21 


-  Epithelium 


Gland  tubule 


Mucosa 


uterus  becomes  much  congested,  the  cervix  softens  and  is  of  a  bluish  color  with 
relaxation  of  the  external  and  of  the  internal  os.  The  uterine  mucous  membrane 
is  also  swollen,  congested,  and  raised  into  folds  which  give  the  surface  an  irregular 
appearance  (Fig.  2);  abundant  secretion  pours  from  the  glands,  and,  at  least  in 
some  cases,  the  epithelium  desquamates,  and  the  capillaries  losing  their  support, 
their  walls  undergo  fatty  degeneration,  burst,  and  discharge  the  blood  (Fig.  4). 
The  tubes  are  also  congested  and  thickened,  and  blood  sometimes  escapes  into 
them.  The  vagina  becomes  darker  in  color,  gland  secretion  is  abundant,  and  the 
temperature  is  slightly  elevated,  often  by  1°  F.  (0.5°  C.)  (Fig.  7).  The  whole 
vulva  is  swollen  and  tense  and  pruritus  may  occur  (herpes  menstrualis). 

Changes  in  the  Endometrium  during  Menstruation. — Various  views  have  been 
held  as  to  the  changes  in  the  uterus  at  this  time.  The  prevailing  view  is  that 
a  certain  amount  of  the  mu- 
cosa, though  small,  is  cast 
off;  that  there  is  fatty  de- 
generation of  the  walls  of 
the  blood-vessels  which  per- 
mits the  outflow  of  blood, 
and  this  is  the  primary 
change  during  menstrua- 
tion. The  flow  arises  from 
diapedesis  of  the  blood-cor- 
puscles. The  amount  of 
blood  is  comparatively  small 
and  does  not  really  consti- 
tute a  true  hemorrhage.  The 
flow  is  preceded  by  altera- 
tions in  the  glands,  which 
become  hypertrophied  and 
present  a  zigzag  appearance 
on  cross-section,  while  the 
cells  in  the  lower  part  of 
the  glandular  structure  may 
become  larger  and  resemble 
epithelial  cells.  The  con- 
nective-tissue cells  also  un- 
dergo hypertrophy  (Figs.  4 
and  3). 

Time    of    Occurrence. — 
As    has    been    stated,    the 

establishment  of  puberty  ushers  in  the  process  of  menstruation.  The  accompany- 
ing physical  changes  give  evidence  of  the  capacity  for  conception  and  child- 
bearing  now  assumed  by  the  woman.  In  temperate  climates  the  average  age  for 
the  beginning  of  menstruation  is  the  fifteenth  year.  There  are,  however,  many 
exceptions  to  this  rule  within  normal  limits,  as  it  is  not  so  very  uncommon  to 
observe  the  beginning  of  this  process  at  the  tenth  or  eleventh  year,  or  its  delay 
to  the  eighteenth  or  twentieth.  The  average  age  in  India  is  said  to  be  the  ninth 
year,  while  in  Iceland  it  is  given  as  the  sixteenth  year.  There  are  recorded 
curiously  abnormal  cases  of  menstruation,  pregnancy,  and  childbirth  in  early 
childhood,  also  of  childbirth  years  after  the  menopause,  which  normally  occurs 
about  the  forty-fifth  year. 

Conditions   Influencing  Menstruation. — Menstruation   is   influenced   by    (i) 


Fig.  3. — Mucous  Membrane  of  the  Resting  Uterus 
OF  A  Young  Woman.  X  35. — (Afier  Bohm  and  von 
Davidojj.) 


22 


PHYSIOLOGY   OF  THE   FEMALE   GENITAL  ORGANS. 


race;  (2)  mode  of  life;  (3)  climate;  (4)  heredity;  and  (5)  genital  sense.  Some 
authors  lay  considerable  stress  on  the  influence  of  race.  It  is  said  that  English  girls 
in  Calcutta  menstruate  no  earlier  than  in  England,  although  subjected  to  the  same 
climatic  influences  as  the  Hindoos,  i  or  2  per  cent,  of  whom  menstruate  as  early 
as  the  ninth  year,  while  25  per  cent,  menstruate  at  twelve  years  of  age.  The 
children  of  the  superior  classes,  being  of  a  higher  nervous  organization,  are  apt  to 
menstruate  earlier.  Their  manner  of  life  is  more  luxurious  and  mental  stimulation 
is  premature,  as  shown  in  the  earlier  period  of  menstruation.     As  to  the  influence 


Disintegrated  surface   ":T..pji^~,Jy'.->f'^. 
Blood-vessels   ■  - '.' j?x>^s^V  fe^: 


Excretory  duct 


._J:?Mv'S^I 


Superficial  epithelium 
Disintegrated  surface 


Glandular  lumen 


^■^C'- ;{■■.U/^'^  — ^P'Kit"  J —  Depression  in  mucosa 

'^^y^\-^^,':^lf?^'':J.':l l':M ■S^-^^'^'^-^A%''^-^^^ —  Excretory  duct 


•-  Gland-tubule 


Blood-vessel 


Blood-vessel 


>--    Muscularis 


Fig.  4. — Mucous  Membrane  of  a  Virgin  Uterus  during  the  First  Day  of  Menstrua- 
tion.     X  30. — (Schafer.) 

of  climate,  it  has  no  doubt  been  exaggerated,  although  the  general  rule  holds  that 
menstruation  occurs  somewhat  earlier  in  the  tropical  than  in  the  arctic  regions. 
Premature  or  late  sexual  development  is  often  noticed  as  a  family  trait.  Sexual 
excitement  is  thought  to  influence  the  advent  of  menstruation,  and  Clay  *  has 
noted  this  excitement  among  the  hard-working  factory  girls  of  Manchester, 
where,  in  the  nature  of  the  work,  there  is  a  promiscuous  mixing  of  sexes.  In  the 
case  of  pregnancy,  menstruation  is  nearly  always  suspended  during  the  whole 
period  of  gestation,  recurring  from  six  to  eight  weeks  after  the  birth  of  the 

*  "Brit.  Record  of  Obstet.  Med.,"  vol.  i. 


MENSTRUATION.  23 

child.  Exceptions  to  the  rule  of  suspended  menstruation  in  pregnancy 
occur  now  and  then  during  the  early  months,  and  are  explained  by  the  fact  that 
the  uterine  cavity  is  not  obliterated  by  the  junction  of  the  decidua  reflexa  and 
the  mucous  membrane  of  the  uterus,  or  the  decidua  vera,  till  the  close  of  the  fifth 
month.  In  case  the  menses  continue  throughout  pregnancy, — a  very  rare  con- 
dition indeed, — there  is  probably  an  abnormal  and  incomplete  fusion  of  the 
deciduag.  Naegele  *  held  that  menstruation  regenerates  the  capacity  for  con- 
ception which  had  failed  by  degrees  during  the  intermenstrual  period.  The 
relation  between  menstruation  and  the  "heat"  of  lower  animals  is  a  very 
interesting  study.  The  most  satisfactory  theory  appears  to  be  that  menstru- 
ation is  caused  by  a  central  nervous  influence  reflected  through  the  sympathetic 
nervous  system  to  the  ovaries  and  uterus. 

The  Menstrual  Cycle. — The  entire  menstrual  cycle  comprises  four  stages 
(Marshall),  and  extends,  as  a  rule,  over  twenty-eight  days:  (i)  The  preparatory 
or  constructive  stage  consists  in  making  ready  for  the  reception  of  the  ovum. 
This  preparation,  according  to  Marshall,  is  probably  made  for  the  ovum  which  is 
discharged  at  the  preceding  period,  for  it  is  probable  that  a  week  is  consumed  in 
the  migration  of  the  ovum  from  the  ovary  to  the  uterus.  When  pregnancy  does 
not  occur,  this  stage  is  followed  by  degenerative  changes.  (2)  The  destructive 
stage  comprises  all  the  ordinary  phenomena  of  menstruation.  It  lasts  about  five 
days,  varying,  however,  according  to  individual  peculiarities.  (3)  The  re- 
parative stage  is  occupied  with  the  regeneration  of  the  destroyed  parts  of  the 
uterine  tissue — the  focus  of  new  growth  being  the  unharmed  deeper  tissues  still 
existing.  This  process  takes  place  in  from  three  to  four  days.  (4)  The  quies- 
cent stage  comprises  the  remaining  twelve  or  fourteen  days  of  the  whole  cycle 
and  just  precedes  the  beginning  of  the  next  period. 

Menstruation  is  Temporary,  Intermittent,  and  Periodic. — It  is  temporary  be- 
cause it  exists  only  during  the  sexual  life  of  the  woman,  asserting  itself  at  puberty 
and  declining  at  the  menopause  till  it  ceases  altogether.  It  is  intermittent 
because  it  comes  and  goes,  and  periodic  because  the  series  of  phenomena  repre- 
senting this  physiological  process  reproduce  themselves  at  intervals  of  usually 
one  month,  being  the  result  of  the  hyperemia  which  occurs  in  the  whole  genital 
system  of  the  woman — ovary,  tubes,  uterus,  and  broad  ligaments.  Periodicity 
is  variable,  but  twenty-eight  days  is  considered  the  normal  period.  Two  sisters 
are  mentioned  in  whom  menstruation  occurred  only  two  or  three  times  a  year 
(Joulin). 

Duration. — The  duration  of  menstruation  averages  five  days,  but  varies  from 
three  to  seven.  Some  cases  are  known  in  which  menstruation  lasts  only  a  few 
hours,  others  in  which  it  lasts  many  days. 

Quantity  of  Blood  Lost. — The  total  amount  lost  varies  normally  from  five  to 
ten  ounces.  The  amount,  even  if  rather  large,  need  not  be  considered  abnormal 
unless  the  general  health  suffers.  High  living,  rich  diet,  and,  indeed,  anything 
that  abnormally  stimulates  mind  and  body,  will  tend  to  increase  the  flow.  Con- 
sequently city-lDred  girls  and  those  of  the  higher  classes  have  a  greater  flow  than 
the  hard-worked  women  of  the  laboring  classes.  It  is  also  greater  in  warm 
climates  than  in  cold,  and  English  women  in  India  menstruate  profusely,  while 
on  their  return  to  England  there  is  marked  decrease  of  the  flow.  The  same  fact 
has  been  noted  in  American  women  moving  from  the  Southern  States  to  the  Lake 
region.  It  appears  that  women  sometimes  menstruate  more  profusely  in  summer 
than  in  winter.  The  daily  loss  is  not  the  same  during  the  period.  It  is  shght  at 
first,  as  a  rule,  reaches  the  maximum  on  the  third  day,  and  then  gradually  de- 
*  "Erfahrungen  und  Abhandlungen,"  Mannheim,  1S12. 


24  PHYSIOLOGY  OF   THE  FEMALE  GENITAL  ORGANS. 

creases.     At  the  last  it  often  ceases  for  a  few  hours  and  then  returns.     Emotion 
or  excitement  of  any  kind  is  very  apt  to  bring  it  on. 

Composition  of  the  Menstrual  Blood. — The  discharge  is  made  up  of  water,  red 
and  white  blood-corpuscles,  mucus-corpuscles,  abundant  epithelial  cells  from  the 
uterus  and  vagina,  and  rarely  strips  of  uterine  mucosa.  Virchow  believes  that 
some  of  the  epithelium  comes  from  the  interior  of  the  uterine  glands.  The  direct 
discharge  from  the  uterus  consists  of  pure  blood,  and  if  it  is  collected  by  the 
speculum  it  will  coagulate.  The  fact  that  ordinary  menstrual  blood  does  not 
coagulate  has  caused  much  speculation.  Mandl  has  given  the  true  explanation 
by  showing  that  small  quantities  of  mucus  or  pus  will  keep  fibrin  in  solution,  and 
that  the  former  is  always  found  in  the  secretions  from  the  cervix  and  vagina  and 
mingles  with  the  blood  in  its  passage  from  the  uterus  to  the  external  world. 
However,  in  case  of  excessive  flow  there  will  not  be  sufficient  mucus  to  act  on  all 
the  fibrin.  The  color  is  generally  dark  at  first,  while  later  it  becomes  paler. 
Women  in  poor  health  often  have  a  very  pale  discharge.  The  amount  of  inter- 
mingled mucus  doubtless  has  much  to  do  with  the  differences  in  color.  The  reac- 
tion is  alkaline.  There  is  always  a  faint  odor  to  menstrual  blood  which  is  char- 
acteristic. It  has  been  likened  to  that  of  marigolds.  It  is  probabty  due  either  to 
decomposing  mucus  or  to  the  mixture  of  the  secretions  of  the  vulvar  sebaceous 
glands.  This  peculiarity  has  been  noted  from  the  earliest  times,  and  even  now 
in  England  on  many  farms  the  old  prejudice  of  the  deleterious  effects  of  menstrual 
blood  is  seen  in  the  custom  of  not  allowing  menstruating  women  to  attend  to  the 
making  of  butter,  preserves,  cheese,  etc.  The  influence  of  menstruation  on  the 
general  health  is  very  apparent.  It  is  quite  common  to  observe  symptoms  of 
marked  toxemia  occurring  a  day  or  two  before  the  flow,  such  as  headache,  nausea 
and  vomiting,  jaundice,  vertigo,  and  high  blood-pressure,  which  subside  upon 
the  establishment  of  the  hemorrhage. 

Modifications  and  Anomalies  of  Menstruation. — At  times  menstruation  occurs 
through  the  skin  of  the  mammae.  This  is  probably  due  to  their  intimate  sympa- 
thetic connection  with  the  generative  organs.  Bleeding  may  also  take  place  from 
the  surface  of  an  ulcer  or  from  hemorrhoids.  All  of  these  locations  are  such  as  to 
give  easy  external  escape  to  the  blood.  In  other  cases  the  bleeding  occurs  from  the 
nose ;  or  there  may  be  vomiting  of  blood  or  bleeding  from  the  lungs.  Cutaneous 
hemorrhage  may  take  place.  Vicarious  menstruation  is  generally  a  sign  of  ill 
health  and  is  usually  seen  in  young  women  of  highly  nervous  organization.  It 
may  begin  at  puberty  and  continue  throughout  the  entire  sexual  life.  Its  occur- 
rence is  periodic,  corresponding  with  the  menstrual  nisus,  although  the  amount 
of  blood  is  generally  considerably  less  than  that  lost  in  normal  menses.  AVe  find 
also  such  abnormalities  as  menorrhagia,  dysmenorrhea,  and  retention  of  menses 
from  obliteration  of  the  neck  of  the  uterus  or  the  vaginal  orifice.  Other  modi- 
fications are  in  the  suppression  of  menstruation  from  pregnancy,  from  lactation, 
or  from  emotion. 

Relation  between  Menstruation  and  Ovulation. — This  relation  is  not  entirely 
clear.  Menstruation  is  not  necessary  to  child-bearing,  but  there  is  a  marked 
connection  between  ovulation  and  menstruation.  Various  theories  are  ad- 
vanced: by  Pfliiger,  that  the  presence  of  the  ripe  follicle  causes  a  reflex  action 
which  brings  on  menstruation;  by  Strassmann,  that  menstruation  is  due  to 
pressure  changes  in  the  ovary.  To  prove  this  he  injected  a  sterile  fluid  into  the 
ovary  and  found  the  animal  went  in  "heat"  as  a  result.  It  has  also  been 
observed  that  on  the  second  or  third  day  after  ovariotomy  the  patient  often 
undergoes  a  pseudo-menstruation,  probably  caused  by  the  pressure  of  the 
Hgatures;  also  that  menstruation  may  continue  after  ovariotomy.     Some  have 


MENSTRUATION.  25 

tried  to  explain  this  by  saying  that  a  portion  of  the  ovary  had  been  left  behind 
or  that  the  discharge  was. due  to  some  pathological  condition  not  noticed  at 
the  time.  These  cases,  however,  are  too  numerous  to  be  explained  on  the  sup- 
position of  a  mistake.  Leopold  showed  that  ova  mature  at  all  times,  both  before 
puberty  and  after  the  menopause,  and  this  was  observed  by  others.  Lowenthal 
thought  that  menstruation  depended  upon  non-fertilization  of  the  ovum;  that 
is,  was  a  primitive  abortion.  Variations  of  three  weeks  have  been  noticed  in  the 
time  of  delivery  corresponding  to  fertilization  just  before  or  just  after  menstru- 
ation. Young  girls  have  also  become  pregnant  before  menstruation  began, 
and  ruptured  follicles  have  sometimes  been  found  in  the  ovary  in  the  inter- 
menstrual period.  Pregnancy  seldom  occurs  during  lactation,  though  men- 
struation begins  much  sooner  than  the  end  of  lactation.  Lawson  Tait 
believed  that  there  are  nerves  from  the  tubes  to  the  sympathetic  system,  and 
these  he  called  menstruating  nerves.  All  of  these  facts  make  the  relationship 
of  menstruation  to  ovulation  somewhat  obscure.  The  following  conclusions, 
however,  may  safely  be  drawn:  Ovulation  and  menstruation  occur  about  the 
same  time,  although  ovulation  often  follows  menstruation  and  may  occur  be- 
tween the  menses.  The  ovarian  changes  which  precede  ovulation,  by  producing 
ovarian  tension,  refiexly  excite  the  uterus  and  cause  menstruation.  These 
changes  are  nearly  or  quite  complete  before  the  bursting  of  the  Graafian  follicle. 
The  time  of  labor  cannot  be  accurately  estimated,  and  rules  for  avoiding  concep- 
tion are  very  uncertain.  Both  ovulation  and  menstruation  are  under  some  ner- 
vous control,  yet  either  process  may  occur  independently.  Conception  is  more 
apt  to  result  from  a  coitus  just  after  a  menstrual  flow  than  at  any  other  time. 
Three  theories  have  been  advanced  as  to  these  relations:  (i)  Ovulation  deter- 
mines menstruation;  (2)  menstrual  congestion  favors  ovulation,  since  there  occur 
simultaneously  congestion  of  the  ovary  and  uterus;  (3)  menstruation  and  ovu- 
lation are  interdependent. 

The  Menopause. — The  climacteric  or  change  of  life  varies  as  widely  as  does 
the  establishment  of  menstruation,  although  the  average  age  is  between  forty  and 
fifty  years.  Cases  of  women  menstruating  till  the  eightieth  or  ninetieth  year, 
which  have  been  reported,  must  be  regarded  as  exceptional  and  as  having  no 
bearing  on  the  general  rule.  The  great  majority  of  women  cease  to  menstruate 
in  the  forty-sixth  year;  most  cases  of  prolonged  menstruation  are  dependent  on 
pathological  conditions — organic  disease  of  some  kind,  malignant  or  otherwise. 
Cases  in  which  menstruation  ceased  between  the  ages  of  thirty  and  forty  years 
are  noted,  certain  instances  being  recorded  as  early  as  the  twenty-fifth  year. 
It  is  the  generally  received  opinion  that  women  who  begin  to  menstruate  early 
cease  to  do  so  at  a  correspondingly  early  period,  so  that  the  average  duration  of 
the  function  is  about  the  same  in  all  women.  But  Cazeaux  and  Raciborski 
think  differently,  and  they  are  upheld  by  the  opinion  of  Guy,  which  he  formed 
from  the  observation  of  1500  cases.  These  authors  think  that  the  earlier  a 
woman  begins  to  menstruate,  the  longer  she  will  continue;  believing  that  early 
menstruation  indicates  extreme  vital  energy,  and  that  this  continues  during  the 
entire  child-bearing  epoch.  Thirty  years  of  sexual  activity  are  considered  the 
normal  duration.  Climate  and  other  accidental  factors  do  not  seem  to  have  so 
much  influence  on  the  cessation  of  menstruation  as  on  its  establishment.  The 
menopause  is  generally  ushered  in  b}^  gradual  changes  in  the  amount  of  discharge. 
There  are  irregularities  in  its  occurrence,  and  a  diminution  in  amount,  or  even  at 
times  an  increase,  till  finally  it  ceases  altogether.  The  genitalia  all  undergo  an 
atrophic  change  and  nervous  phenomena  appear  (Fig.  5).  Flashes  of  heat  are 
very  characteristic,  and  both  the  physical  and  mental  being  may  undergo  altera- 


26 


PHYSIOLOGY  OF   THE  FEMALE  GENITAL  ORGANS. 


tions.  There  is  a  more  or  less  constant  tendency  to  obesity  at  the  time.  The 
notions  among  the  laity  as  to  the  great  dangers  of  the  menopause  are,  without 
doubt,  greatly  exaggerated.  It  is  not  uncommon  to  see  a  woman  who  for  years 
has  suffered  from  uterine  and  other  complaints  seem  to  enjoy  robust  health  after 
this  trying  period  has  been  passed.  Statistics  conclusively  prove  that  mortality 
at  this  time  is  no  greater  than  at  any  other  period.  Some  have  noted  that  in 
certain  cases,  especially  of  unmarried  women,  there  is  a  loss  of  feminine  traits 


LINE  OF'SECTION 


Crural  nerve 

Psoas  muscle 

Iliac  muscle 

'  al  artery  ( injected) 

undibiilo-pelvic  liga- 

m.ent 

>)emng  of  right  tube 

Obturator  artery 

ngin  of  uterine  and 

vesicular  arteries 

Broad  ligarnent 

Right  ovary 

Mesenterium  tubts 

fiddle  hemorrhoidal 

artery  j?7;g-Ai'  ureter 

Right  tube 

Co7n»wn  pudic  art. 

Transverse  sec.  of  round  lig- 

Gluteal  miiscle 

Transverse  sec.  of  rectum 


Fig.  5. — Atrophy  and  Prolapse  of 


Rectum 
Crural  nerve 
Crural  artery  {injec 
Med.  and  small  glut, 

m.uscle 
Obturator  nerve 
Obturator  artery 
Origin  of  uterine  ar 
vesicular  arteries 
Ligament,  latum  cov 
Left  ureter.      [left  < 

Left  broadjigameni 
Ischialjierve 

Middle  hemorrhoidi 

artery 

~  Left  t,^be 

Ant.  border  of  pyriform.  muscle 

Transverse  sec.  of  round  lig. 

Common  pudic  art. 
Retroverted  uterine  body 

Douglas^  pouch 

Uterus  and  Adnexa  following  the  Menopause. — 


and  the  assumption  of  certain  anatomical  male  characteristics — a  more  an- 
gular form,  a  harsher  voice,  or  even  the  development  of  an  imperfect  beard  or 
moustache. 


III.  INSEMINATION. 

Definition. — By  insemination  is  meant  the  deposition  of  the  seminal  fluid 
within  the  genital  tract  of  the  female  during  sexual  intercourse. 

Phenomena. — Before  conception  can  take  place  there  must  be  a  meeting  and 
fusion  of  the  vital  elements  of  the  two  sexes.  This  is  brought  about  by  coitus  or 
copulation,  by  means  of  which  the  semen  of  the  male  is  deposited  in  the  vagina  of 
the  female.  This  act  is  called  insemination,  although  fecundation  does  not  follow 
unless  the  ovum  and  spermatozoon  come  together  and  amalgamate.  When  this 
occurs,  the  woman  conceives  and  enters  upon  the  period  of  pregnancy  or  gesta- 
tion. The  orgasm  is  the  climax  of  the  sexual  act.  Its  normal  occurrence  is 
simultaneous  in  the  male  and  female,  and  makes  conception  more  probable. 
When  it  is  not  simultaneous,  the  cervical  alkaline  mucus  protects  the  spermatozoa 


Fig.   6. — Breast  of  a  Nulli parous,  Married   Woman   a   Few    Days    Before  a   Menstrual 
Period,  Showing  Changes  Identical  with  Those  Produced  by  Pregnancy. 


*  S»  irf  to      -<•   "  fjsk 


Fig.    7. — Vaginal   ^^[urous    -Memhrane  of   .v    Nulliiwrous    \\'oman   the    First   Day    of 

]\fENSTKUAL    PEk lOU.  S llOWING    CHANGES    ANALOGOUS    TO     I'lUiSE    PkoDUCEI)    T.V  PkEGNANCV. 


IMPREGNATION. 


27 


from  the  acid  secretion  of  the  vagina.  The  collection  of  semen  covering  the 
cervix  permits  the  spermatozoa,  by  virtue  of  their  inherent  power  of  locomo- 
tion, to  enter  the  uterus.  This  explains  the  occurrence  of  conception  in  cases 
in  which  the  woman  has  been  apathetic  during  sexual  intercourse,  having  no 
orgasm,  or  when  she  was  unconscious  from  any  cause.  The  time  at  which  insemi- 
nation is  least  likely  to  be  followed  by  fertilization  is  from  the  seventeenth  to  the 
twenty-third  day  after  menstruation  has  ceased.  It  is  most  apt  to  occur  on  the 
first  day  after  menstruation. 


IV.   IMPREGNATION. 

Synonyms. — Fertilization;  Incarnation;  Fecundation. 

Definition. — By  impregnation  is  meant  the  union  of  the  ovum  and  the  sperma- 
tozoon. A  woman  who  has  never  given  birth  to  a  child  is  called  nulliparous,  or  a 
nullipara,  and  her  condition  is  termed  nulliparity.  The 
state  of  capacity  for  having  children  is  called  parity. 
When  a  woman  is  pregnant  for  the  first  time  she  is  said 
to  be  a  primipara,  or  a  primigravida,  or  a  primigravidous 
woman,  or  in  the  condition  of  primigravidity.  In  suc- 
ceeding pregnancies  she  is  a  multipara,  or  a  multigravida, 
a  multigravidous  woman,  or  in  the  state  of  multiparity. 

The  Semen. — The  medium  by  which  the  spermatozoa 
reach  the  female  generative  organs  is  the  semen.  The 
semen  is  a  thick,  viscid,  albuminous  fluid,  whitish,  yel- 
lowish, or  opalescent  in  color,  with  a  peculiar  odor  that 
has  been  likened  to  lime  or  to  the  filings  of  bone.  It 
consists  of  the  secretion  of  the  testicles  together  with  that 
of  the  prostate  and  Cowper's  glands.  It  is  composed  of 
the  liquor  seminis,  in  which  are  found  microscopically 
the  seminal  granules  and  numerous  minute  anatomical 
elements  termed  spermatozoa,  which  are  the  vital  ele- 
ments. The  liquor  seminis,  which  on  chemical  exam- 
ination yields  82  per  cent,  of  water,  holds  in  solution  a 
mucilaginous,  odoriferous  body  called  spermatin,  as  well 
as  protein  matter,  fats,  phosphates,  chlorides,  and  other 
inorganic  materials. 

The  Spermatozoa. — Each  spermatozoid  (Fig.  8)  consists  of  a  flat  oval  head, 
which  measures  about  -g-oVo  iiich  (3-5-0  mm.)  in  width,  and  represents  the  nucleus 
of  an  epithelial  cell;  a  small  body,  and  a  very  long  fiHform  tail,  or  flagellum, 
which  in  the  living  spermatozoon  is  in  constant  motion.  The  general  appearance 
of  a  spermatozoid  is  that  of  a  tadpole.  These  little  bodies  come  from  the  special- 
ized sperm  cells  of  the  epithelium  of  the  seminal  tubules  in  the  testicles.  The 
profile  of  the  spermatozoid  is  pyriform  in  shape,  and  its  entire  length  is  -g-J-g-  to 
j|-Q-  inch  (0.05  to  0.06  mm.).  The  spermatozoa,  the  most  important  elements, 
are  not  passive  constituents  of  the  liquor  seminis,  simply  floating  in  this  medium ; 
they  are  endowed  with  motility,  and  seem  to  dart  hither  and  thither  as  though 
endowed  with  volition.  It  is  difficult  to  realize,  in  watching  the  curious  move- 
ments of  these  minute  organisms,  as  they  advance  now  en  masse,  now  singly,  at 
times  diving  down,  then  coming  to  the  surface  again,  then  in  their  gyrations 
skilfully  avoiding  obstacles  many  times  their  size,  that  they  are  not  to  a  certain 


Fig.  8. — Human  Sper- 
matozoa. X  360.  I. 
Viewed  from  the  sur- 
face. 2.  Viewed  in  pro- 
file. 3.  Coiled  seminal 
filament.  4.  Sperma- 
tozoon of  bull:  a,  head; 
h,  middle-piece;  c, 
main-piece.  The  end- 
piece  and  the  demar- 
cation of  these  parts 
cannot  be  perceived 
with  this  magnifica- 
tion.— (Stdhr.) 


28  PHYSIOLOGY   OF   THE   FEMALE  GENITAL  ORGANS. 

extent  possessed  of  the  power  of  voluntary  motion.  However,  these  motions 
are  doubtless  due  to  the  undulatory  vibrations  of  the  tail,  which  depend  purely 
upon  molecular  tissue  changes  like  those  which  give  rise  to  the  movements  of 
ciliated  epithelium,  or  to  the  ameboid  movements  of  protoplasm.  The  rate  of 
motion  of  the  spermatozoa  has  been  variously  estimated;  Henle  states  that  they 
travel  an  inch  in  seven  to  twelve  minutes,  or  from  the  hymen  to  the  cervix  in 
three  hours  (Sims).  They  have  been  found  within  the  female  genital  .organs, 
with  their  power  of  motion  unimpaired,  eight  to  ten  days  after  they  were  deposited 
there.  As  soon  as  the  spermatozoa  are  deprived  of  this  motility  their  vitalizing 
power  is  lost.  Environment  has  much  to  do  with  the  retention  of  this  power. 
Extreme  heat  or  cold  or  excessively  acid  or  alkaline  secretions  will  destroy  them. 
Mercuric  chloride  has  a  most  untoward  effect  upon  them,  as  have  also  the  mineral 
poisons  and  lack  of  water.  They  may  be  dead  when  ejaculated,  as  the  result  of 
disease  or  catarrh  of  the  seminal  vesicles  or  alcoholic  or  sexual  excess;  or  they 
may  be  absent  from  the  seminal  fluid  in  consequence  of  anatomical  defect,  or 
inflammation  and  obliteration  of  the  seminal  ducts.  The  seminal  granule,  or 
accessory  corpuscle,  is  that  part  of  the  cell  which  is  extruded  in  the  development 
of  the  spermatozoon,  and  is  analogous  to  the  polar  globule  in  the  maturation  of 
the  ovum.  The  fifteenth  or  sixteenth  year  marks  the  first  appearance  of  the 
spermatic  particles  in  the  sexual  discharge ;  although  there  is  frequently  a  seminal 
discharge  several  years  earlier,  it  seldom  contains  these  elements.  Very  often 
spermatozoa  disappear  from  the  seminal  fluid  of  old  men,  sixty-five  years  being 
the  average  age,  though  many  exceptions  to  this  rule  are  on  record.  The  amount 
of  spermatic  fluid  ejaculated  in  sexual  congress  averages  about  i  dram  (3.7  c.c.) 
and  the  number  of  spermatozoa,  as  estimated  by  Lode,  is  226,257,900.  If  much 
in  excess  of  this,  the  condition  is  termed  polyspermism;  while  if  much  less,  the 
condition  is  pathological,  and  is  designated  as  oligospermism. 

Ascent  of  the  Spermatozoa, — Many  theories  have  been  suggested  as  to  the 
method  by  which  the  spermatozoa  reach  the  uterus.  Litzmann,  Wernicke,  and 
Beck  proposed  the  aspiration  theory,  according  to  which  the  hood-like  layer  of  the 
uterus  contracts,  forcing  the  cervix  down  into  the  lake  of  spermatic  fluid,  then,  re- 
laxation following,  the  semen  is  aspirated  into  the  canal.  Marion  Sims'  view  has 
been  received  with  the  greatest  favor.  It  is  that  the  semen  forms  a  lake  in  the 
posterior  cul-de-sac,  and,  the  cervix  dipping  in,  the  fluid  passes  up  into  the  uterus. 
A  proof  of  the  truth  of  this  theory  is  offered  by  the  observation  of  the  great 
infrequency  of  pregnancy  in  cases  in  which  uteri,  after  operation,  cannot  dip  into 
the  spermatic  fluid.  It  was  formerly  thought  that  the  current  produced  by  the 
cilia  of  the  uterus  carried  the  spermatozoa  along  their  upward  path,  while  the 
tubal  cilia  wafted  the  ovum  toward  the  uterus;  but  Hofmeier,  several  years  ago, 
showed  that  the  ciliary  motion  was  all  in  the  same  direction,  toward  the  outlet 
of  the  uterus.  Tubal  pregnancy  shows  that  the  spermatozoa  must  get  into  the 
tube  by  their  own  inherent  motion.  Occasional  cases  of  pregnancy  in  which 
conception  occurs  through  a  minute  opening  and  an  almost  imperforate  hymen 
prove  the  extreme  motility  inherent  in  the  spermatozoa. 

Place  of  Meeting  of  Spermatozoon  and  Ovum. — Various  authorities  have 
located  the  point  of  fecundation  in  the  uterus,  tubes,  and  ovary,  and  isolated 
observations  are  on  record  showing  that  fecundation  may  take  place  in  any  one 
of  these  organs,  as  the  spermatozoa  reach  the  uterus  by  reason  of  their  own 
motility,  aided  by  other  mechanism,  whence  they  pass  to  the  tube  and  wait  for 
the  ovum,  which  may  or  may  not  be  fertilized. 

Relation  between  Impregnation  and  Menstruation. — It  has  been  practically 
proved  from  observations   on  the  wives  of  sailors  and  from  artificial  impregna- 


IMPREGNATION.  29 

tion*  that  the  most  favorable  time  for  impregnation  is  immediately  after  men- 
struation ;  and  also  that  the  spermatozoa  may  retain  their  vitality  in  the  vagina  for 
at  least  seventeen  days,  even  through  a  menstrual  period.  Instances  are  known  in 
which  insemination,  occurring  just  before  a  menstrual  period,  was  followed  by 
pregnancy  and  delivery  at  term.f  Menstruation  under  such  circumstances  may  be 
perfectly  normal,  and  the  downward  current  of  blood  does  not  interfere  with  the 
upward  passage  of  the  spermatozoa  to  the  Fallopian  tubes.  Hist  examined 
sixteen  embryos  with  the  utmost  care.  He  found  that  in  twelve  the  stage  of 
development  proved  that  impregnation  had  occurred,  not  at  the  time  of  the  last, 
but  at  what  would  have  been  the  next,  menstrual  (first  missed)  epoch,  had  not 
the  woman  become  pregnant.  The  remaining  four  embryos  in  their  develop- 
ment corresponded  to  impregnation  occurring  at  the  last  menstrual  period. 
Duncan  says,  in  this  connection,  that  when  a  fertilizing  insemination  takes  place 
just  before  the  period  is  due,  the  latter  frequently  "does  not  take  place  at  all,  or 
only  very  scantily;  the  uterine  system,  as  it  were,  anticipating  the  conception 
and  preventing  the  failure  which  might  result  from  a  free  discharge  of  blood." 
It  is  quite  evident  that  such  cases,  occurring  in  married  women,  would  be  very 
liable  to  be  considered  "cases  of  gestation  protracted  a. month." 

Unconscious  Impregnation. — A  woman  may  become  pregnant  in  a  state  of 
partial  or  complete  unconsciousness.  In  cases  of  rape  young  girls  have  been 
impregnated  while  unconscious  as  the  result  of  fright,  a  blow,  drugs,  or  alcohol. 
Impregnation  during  unconsciousness  as  the  result  of  anesthetics,  chloroform, 
ether,  or  nitrous  oxide  is  also  possible.  Artificial  impregnation,  the  seminal  fluid 
having,  with  suitable  instruments,  been  injected  directly  into  the  uterus,  has 
also  been  successfully  performed.  Brouardel,^  who  has  studied  and  written 
upon  this  subject,  states  that  copulation  and  impregnation  can  occur  in  a  woman 
without  her  knowledge  during  hypnotic  sleep.  "That  a  woman  should  be  un- 
conscious both  of  the  fact  of  sexual  intercourse,  and  also  continue  unconscious  of 
the  resulting  pregnancy  up  to  the  birth  of  the  child,  we  decline  to  believe,  unless 
she  was  feeble-minded  or  idiotic."     (Reese.) 


V.  RAPE.II 

Definition. — Rape,  derived  from  raptus  mulierum,  signifies  carnal  knowledge 
of  a  female  by  a  man,  forcibly  and  unlawfully,  without  her  consent.  It  may, 
however,  be  committed  by  fraud  or  by  intimidation. 

Law  of  Rape. — Common  law  declares  a  female  under  thirteen  years  of  age 
incapable  of  giving  consent.  Carnal  knowledge  between  thirteen  and  sixteen  is 
regarded  as  a  misdemeanor ;  it  is  not  a  crime  if  the  age  is  over  sixteen  and  there  is 
consent.  The  testimony  of  the  prosecutrix  alone  is  considered  legally  com- 
petent, since  she  and  the  offender  are  generally  without  other  witnesses.  As 
false  accusations  of  rape  are  common,  the  corroborative  testimony  of  medical 
evidence  is  generally  required.  In  600  accusations  I  could  find  evidences 
of  penetration  in  but  386   instances.     In    212   there  was   no   evidence  what- 

*  Bossi:  "  Nouvelles  Archives  d'0bst6trique  et  de  Gyn^cologie,"  Paris,  April,  1S91. 

t Milne  Murray:  "Edinburgh  Med.  Jour.,"  Sept.,  1S92. 

t  "Anatomie  menschl.  Embryonen,"  Abth.  I.  V.,  II.,  Leipzig,  1SS2. 

§  "  Gaz.  des  Hopitaux,"  1S77. 

II  See  more  exhaustive  article,  "Medico-legal  Consideration  of  Rape,"  by  Edgar  and 
Johnston,  "Medical  Jurisprudence,  Forensic  Medicine  and  Toxicology.',"  Witthaiis  and 
Becker,  vol.  11. 


30  PHYSIOLOGY  OF   THE  FEMALE  GENITAL  ORGANS. 

ever  of  penetration  of  the  genital  organs  and  in  two  cases  menstruation  and 
chancroids  rendered  the  diagnosis  uncertain.  The  examination  should  be  made 
as  soon  as  possible  after  the  assault,  and  the  physician  should  carefully  note  the 
time  of  his  examination  and  try  to  obtain  by  inquiry  the  exact  time  of  assault. 
The  female  should  be  allowed  no  time  to  prepare  for  the  examination.  Several 
points  should  be  kept  in  mind  and  noted  by  the  physician:  (i)  Signs  of  violence 
on  the  genitals  of  the  female;  (2)  signs  of  violence  on  her  body  or  that  of  the 
defendant;  (3)  evidence  of  blood  or  semen  on  the  body  or  clothes  of  either;  (4) 
the  existence  of  venereal  disease,  syphilis,  chancroid,  or  gonorrhea,  in  one  or  both 
of  the  individuals  concerned.  The  evidence  of  masturbation  and  criminal 
assault  may  be  present  in  the  same  instance,  and  in  the  majority  of  cases  the 
medical  expert  can  swear  only  to  the  "penetration  of  some  blunt  instrument." 
The  subject  may  be  treated  in  four  parts:  (i)  Rape  on  females  after  puberty; 
(2)  rape  on  children  and  infants;  (3)  rape  by  boys  and  women;  (4)  rape  on 
the  dead  (necrophilia).     False  accusations  are  considered  throughout  the  text. 

I.  Rape  on  Females  after  Puberty. — The  fourchette  and  posterior  commissure 
are  often  destroyed  by  the  first  delivery,  but  they  are  seldom  injured  by  sexual 
intercourse.  In  386  penetrations  the  fourchette  was  lacerated  in  but  17  of  the 
cases  observed  by  me.  The  hymen  is  the  most  convincing  sign  of  virginity.  It  is 
a  membranous  structure  guarding  the  entrance  to  the  vagina  and  making  a  line  of 
demarcation  between  it  and  the  external  genitals.  There  are  four  chief  forms, 
with  many  variations.  These  are:  (i)  A  form  with  a  central,  antero-posterior 
opening;  (2)  the  semilunar;  (3)  the  annular;  and  (4)  the  diaphragmatic. 
(Figs.  9  to  33.)  *  The  first  and  third  are  the  most  common  varieties.  The  imper- 
forate hymen  is  a  pathological  condition.  Is  the  presence  of  an  intact  hymen 
evidence  of  virginity?  Although  the  presence  of  the  hymen  is  not  absolutely 
invariable,  still  it  is  unquestionably  the  most  valuable  physical  sign.  However, 
even  when  it  rem.ains  uninjured,  it  does  not  offer  positive  proof  that  rape  has  not 
been  committed.  This  is  especially  true  in  the  case  of  young  children,  in  whom 
it  is  deeply  placed,  and  the  organs  are  undeveloped;  for  it  must  be  remembered 
that  the  slightest  penetration  is  a  crime.  Authentic  cases  in  which  prostitutes 
have  had  perfectly  preserved  hymens  are  on  record. f  It  may  even  persist  after 
delivery,  remaining  as  a  loose  ring. J  Does  the  absence  of  the  integrity  of  the 
hymen,  on  the  contrary,  indicate  defloration?  The  greatest  care  must  be  exer- 
cised in  deciding  this  question.  The  hymen  may  be  injured  manually,  as  in  one 
of  my  cases  by  a  midwife;  or  it  may  be  destroyed  by  accident,  as  by  falling 
astride  of  an  object;  again,  violent  exercise  may  rupture  it — e.  g.,  horseback- 
riding.  Congenital  absence  of  the  hymen  is  known  (Fig.  35).  Surgical  opera- 
tions or  vaginal  examinations,  roughly  conducted,  not  infrequently  cause  rup- 
ture. The  breasts  are  only  slightly  affected  by  handling  and  sexual  indulgence. 
One  sign  alone  cannot  afford  positive  proof  of  virginity,  but  all  taken  together 
give  assurance  of  it.  It  is  well  known  that  the  use  of  vaginal  astringents  may 
tone  up  and  narrow  the  vagina  and  even  restore  the  hymen  to  a  great  degree.  In 
complete  recent  defloration  the  hymen  will  furnish  the  most  convincing  proof, 
but  the  external  genitals  may  also  be  inflamed  to  a  greater  or  less  extent ;  and  if 
the  inflammation  is  extreme  the  patient's  movements  will  be  interfered  with  and 
she  will  evince  a  great  dread  of  opening  the  thighs.  These  signs  are  most  im- 
portant and  are  seldom  simulated.     There  may  also  be  signs  of  violence  on  the 

*Figs.  9  to  33  inclusive,  and  Fig.  35,  are  from  E.  Von  Hofmann's  "Atlas  of  iLegal 
Medicine." 

t  Grey's  "  Forensic  Medicine,"  p.  49. 

J  Stolz:  "Annales  d'Hygi^ne,"  1873,  t.  2,  p    148. 


RAPE. 


31 


Fig.  9. — Circular  Hymen 
WITH  Wide  Opening  and 
Circular  Smooth-edged 
Margin  of  Equable 
Height  Throughout, 


Fig.  10. — Semilunar 
Hymen. 


Fig.  II. — Semilunar 
Hymen. 


,.  if^^' 


Fig.  12. — Hymen  of  Newly  Fig.   13. — Circular   Hymen  Fig.    14. — Deep   Irregular 

Born   Child   with    Deep  with    Deep    Congenital  Notch  of  the  Hymen  of 

Notches    to    the    Right  Notches.   Edges   Smooth  a  Newly  Born  Infant. 

AND  Left.  and  Rounded. 


Fig.  15. — Congenital  Deep 
Irregular  Notch  of  Hy- 
men. 


Fig.   16. — Fimbriated  Hy- 
men in  a  Virgin. 


Fig.  17. — Serrated  or  Fim- 
briated Hymen  in  a  Vir- 
gin. 


32 


PHYSIOLOGY  OF  THE  FEMALE  GENITAL  ORGANS. 


Fig.  i8. — Hymen  Bipartus 
OR  Septus  or  Divided  Hy- 
men. 


Fig.  19. — Hymen  Bipartus 
orSeptus  or  Divided  Hy- 
men. 


Fig.  20. — Hymen  Septus  in 
AN  Unmarried  Woman 
Twenty-four  Years  Old. 
Strong  and  Thick  Sep- 
tum. 


P^^. 


T^l'Cf 


Fig.  21. — Large  and  Small 
Openings  in  a  Divided 
Circular  Hymen. 


Fig.  22.— Circular  Hymen  Fig.  23. — Circular  Hymen 
OF  AN  Adult  Parous  of  Virgin,  Age  Twenty 
Woman.  Years.       Hymen    Partim 

Septus. 


Fig.  24. — Circular  Hymen 
with  Congenital  Trans- 
verse Septum  in  Girl  of 
Seventeen 


Fig.  25. — Divided  Hymen  Fig.  26. — Circular  Hymen 
of  Infant  with  Thick  of  Child,  Age  Twelve, 
Transverse  Septum.  Ruptured     by     Rape. 

Death  in  Ten  Days  from 
Peritonitis. 


RAPE. 


33 


Fig.  27.— Circular  Hymen 
WITH  Old  Healed  Lac- 
eration TO  Left  and 
Right. 


Fig.   28. — Remains    of   Hy-  Fig.  29. — Hymen  after  Sev- 

MEN    Six    Months    after  eral  Labors.     Shape  Or- 

Delivery  at  Term.  Car-  iginally  Circular. 

UNCULiE   MyRTIFORMES. 


Fig.  30. — Divided  Hymen 
OF  A  Prostitute  Eigh- 
teen Years  Old.  Coitus 
Took  Place  through  the 
Left  Opening. 


Fig.  31. — Remains  of  a  Di- 
vided Hymen  after  De- 
floration AND  Parturi- 
tion. 


Fig.  32. — Hymen  from  a 
Woman,  Age  Twenty- 
nine,  Who  Died  in  Sixth 
Month  of  First  Preg- 
nancy. Originally  a  Di- 
vided Circular  Hymen. 


.^^i^.y-*- 


FiG.  33. — Hymen  from  El- 
derly Multiparous 
Woman. 


Fig.  34. — Parental  Rape 
ON  Infant  Eight  Months 
Old.  Complete  Lacera- 
tion OF  Pelvic  Floor. — 
(New  York  Children's  So- 
ciety.) 


-# 


r~ 


--•>* 


Fig.  35. — Congenital  Ab- 
sence OF  Hymen.  Mas- 
culine    PSEUDOHERMAPH- 

rodism.  Female  Infant 
WITH  Normal  Internal 
AND  Hermaphroditic  Ex- 
ternal Organs. 


34  PHYSIOLOGY  OF  THE  FEMALE  GENITAL  ORGANS. 

genitals,  thighs,  abdomen,  or  perineum.  The  hymeneal  tear  itself  may  be 
attended  with  pain  and  difficulty  in  walking.  Attention  should  be  paid  to  the 
manner  in  which  the  hymen  is  torn,  as  well  as  to  the  appearance  of  the  edges  of 
the  segments.  As  a  rule,  healing  takes  place  in  from  eight  to  twelve,  or  at  most 
twenty,  days.  Rarely  the  tears  of  the  hymen  unite;  if  they  do,  a  cicatrix  may 
remain.  Incomplete  recent  defloration  is  usually  seen  in  young  children.  Non- 
recent  defloration  may  be  told  chiefly  from  the  absence  of  a  complete  hymen,  its 
remnants  only  remaining.     The  vulval  canal  is  likely  to  be  dilated. 

Conditions  Simulating  Defloration. — Traumatism,  all  ulcerative  and  gangren- 
ous affections  of  the  pudendum,  chancre,  chancroid,  mucous  patches,  and  herpes 
progenitalis  may  each  cause  such  destruction  that  the  results  may  simulate 
those  caused  by  intromission.  An  extreme  degree  of  leucorrhea  or  an  excessive 
menstrual  discharge  may  cause  dilatation  of  the  vagina  and  superficial  ulceration 
of  the  mucous  membrane,  like  that  produced  by  coitus.  Again,  marks  of  vio- 
lence must  be  considered.  Stains  of  blood  and  semen  should  be  carefully  exam- 
ined. Vaginal  discharges  must  be  scientifically  considered.  Leucorrhea  must 
be  differentiated  from  gonorrhea. 

Can  a  woman  be  violated  against  her  will?  The  best  authorities  believe  fully 
that  a  mature  woman,  in  full  possession  of  her  faculties,  cannot  be  raped  by  a 
single  man  against  her  will.  In  the  case  of  a  child  or  an  old  woman,  or  when 
there  are  two  or  more  assailants,  the  conditions  are  very  different.  Terror  may 
in  certain  instances  cause  paralysis.  Can  rape  be  accomplished  during  natural 
sleep?  This  is  probably  unlikely,  indeed  impossible,  in  the  case  of  a  virgin. 
Rape  by  fraud,  unfortunately,  is  widely  prevalent,  as  in  the  impersonation  of  a 
husband.  Rape  on  psychopathic  individuals,  in  the  hypnotic  state,  and  during 
unconsciousness  from  narcotism,  alcoholism,  and  anesthesia  has  occurred. 

2.  Rape  upon  Children  and  Infants. — This  is  far  more  common  than  the 
crime  on  adults,  for  it  is  easier  to  perpetrate,  and  there  is  a  wide-spread  super- 
stition among  some  nationalities  that  intercourse  with  a  virgin  is  a  sure  cure 
for  venereal  disease.  On  account  of  the  disproportion  between  the  organs,  the 
crime  usually  consists  in  placing  the  head  of  the  penis  between  the  labia  majora 
or  the  thighs  of  the  child.  There  are  great  differences  between  the  genital  organs 
of  the  child  and  the  adult.  The  whole  vulval  canal  is  relatively  much  longer  in 
youth  than  after  puberty.  It  is  important  to  examine  the  fourchette  and  com- 
missure for  evidence  of  rape  in  children,  since,  on  account  of  the  very  small  open- 
ing, injury  is  more  common  in  their  case  than  in  that  of  mature  women.  The 
hymen  is  very  deeply  situated  in  the  child  and  there  is  almost  no  possibility  of 
intromission.  The  pubic  arch,  as  well  as  the  vagina  and  its  entrance,  are  very 
narrow.  One  of  my  600  cases  was  rape  by  a  father  upon  his  daughter  eight 
months  old,  causing  complete  laceration  of  the  perineum  from  vagina  to  rectum. 
The  hemorrhage  was  controlled  and  the  perineum  repaired  with  sutures  (Case 
No.  70,542)  (Fig.  34). 

G.  P.;  bom  in  United  States;  aged  eight  months;  seen  February  17,  1893,  soon  after 
assault.  The  external  genital  organs  were  found  to  be  greatly  swollen,  contused,  and  oedema- 
tous.  Complete  laceration  was  foiuid  to  have  occurred  at  the  vaginal  and  rectal  orifices, 
■causing  loss  of  tissue  between  these  two  orifices  and  for  some  distance  up  on  the  recto-vaginal 
■septum,  so  that  the  vaginal  and  anal  orifices  appeared  as  one,  surrounded  by  a  bleeding 
■mass  of  lacerations.  The  child  was  removed  to  a  hospital  and  an  operation  requiring  the 
introduction  of  several  sutures  was  necessary  to  control  the  bleeding  and  partially  to  repair 
the  torn  parts  and  restore  them  to  their  original  condition.  Defendant  in  this  case  was 
■charged  with  attempt  at  rape,  pleaded  not  guilty,  was  adjudged  insane,  and  committed 
to   tiie  State  Asylum  for  Insane  Criminals  at  Matteawan. 

3.  Rape  by  Boys  and  Women. — Erections  are  known  to  be  possible  at  four 


HYGIENE  OF  THE  SEXUAL  FUNCTIONS.  35 

years  of  age,  although  both  in  this  country  and  in  England  a  boy  under  seven 
years  cannot  legally  commit  a'  felony.  Rape  by  women,  or  rape  by  females  on 
males,  is  not  uncommon.  It  is  generally  committed  by  an  adult  woman  to  gratify 
a  perverted  sexual  instinct,  or  while  in  a  state  of  nymphomania.  There  is  a  super- 
stition among  the  ignorant  that  the  act  will  cure  venereal  disease. 

4.  Rape  on  the  Dead,  or  Necrophilia. — This  subject  must  not  be  confused  with 
that  which  deals  with  the  evidence  of  rape  found  on  the  dead  body,  the  crime 
having  been  committed  before  death.  The  history  of  this  revolting  deed  extends 
back  through  the  ages.  In  the  State  of  New  York  this  crime  is  punishable  by 
the  maximum  penalty  of  twenty  years  of  imprisonment.*  Physical  evidence  of 
it  would  be  difficult  if  it  were  not  seen.  Several  instances  of  this  crime  occurred 
in  the  old  New  York  city  morgue. 

Statistics. — In  my  study  of  600  consecutive  examinations  for  evidence  of  rape  made  in 
New  York,  for  the  Society  for  the  Prevention  of  Cruelty  to  Children,  I  obtained  the  following 
statistics:  Age:  The' yoiongest  child  was  eight  months,  the  oldest  eighteen  years,  and  the 
average  age  was  eleven  years.  Nativity:  405,  or  67.50  per  cent.,  were  native  bom;  65,  or 
10.83  per  cent.,  were  Italians;  36,  or  6  per  cent.,  were  Germans;  23,  or  3.83  per  cent., 
Russians;  13,  or  2.16  per  cent.,  Enghsh;  10,  or  1.66  per  cent.,  Austrians;  8,  or  1.33  per 
cent.,  Irish;  4,  or  0.66  per  cent.,  Scotch;  4,  or  0.66  per  cent.,  Swiss;  4,  or  0.66  per 
cent.,  Hvmgarians;  3,  or  0.50  per  cent.,  French;  3,  or  0.50  per  cent.,  Belgian;  and  2,  or 
0.33  per  cent.,  Bohemian.  Marks  oj  a  struggle:  I  found  marks  of  a  struggle  in  only 
15  cases,  or  2.50  per  cent.  These  included  abrasions,  contusions  of  the  thighs,  groins, 
buttocks,  shoulder,  and  arm,  11  cases,  or  1.83  per  cent.;  scratches  of  the  hand  and  face,  3 
cases,  or  0.50  per  cent.;  and  black  eye  in  i  case,  or  0.17  per  cent.  Condition  oj  the  external 
genitals:  Contusions,  abrasions,  or  lacerations  were  present  in  21  cases,  or  3.60  per  cent.; 
vulvo- vaginal  abscess  in  i  case,  or  0.17  per  cent.;  chancres  or  chancroids  in  18  cases,  or 
3.01  per  cent.;  the  fourchette  was  lacerated  in  17  cases,  or  2.83  per  cent.  The  hymen  was 
found  to  have  been  ruptured  in  338,  or  57.46  per  cent,  of  cases;  inflamed  in  7  cases,  or  1.19 
per  cent.;  stretched  in  11  cases,  or  1.83  per  cent.;  contused  in  i  case,  or  0.17  per  cent.; 
and  abraded  in  2,  pr  0.33  per  cent,  of  cases.  Secretions:  A  muco-purulent  or  purulent 
discharge  was  found  in  67  cases,  or  11. 16  per  cent.;  the  gonococcus  was  found  in  16  cases, 
or  2.66  per  cent.;  and  spermatozoa  in  2,  or  0.33  percent.  Impregnation,  as  far  as  the 
cases  could  be  followed,  was  known  to  have  occurred  in  22,  or  4  per  cent.  Undoubtedly 
this  is  a  low  percentage,  as  many  cases  passed  from  observation.  Penetration  of  the 
genital  organs  by  a  blunt  instrument  was  considered  to  have  been  recent  in  character  in 
201,  or  ^7,  per  cent.;  non-recent,  in  180,  or  30  per  cent.,  and  both  recent  and  non-recent 
in  5  cases.  Penetration  was  thus  determined  in  386  cases,  or  65  per  cent.  In  2  cases, 
because  of  menstruation  and  venereal  sores,  it  was  impossible  to  determine  whether  pene- 
tration had  occurred  or  not.  This  leaves  212  cases,  or  35  per  cent.,  in  which  there  was  no 
evidence  whatever  of  penetration  of  the  genital  organs. 


VI.   HYGIENE  OF  THE  SEXUAL  FUNCTIONS. 

The  health  of  the  young  girl  should  be  most  carefully  guarded  with  a  view  of 
preserving  the  integrity  and  vitality  of  the  sexual  functions.  The  difference  in 
vigor  between  the  American  women  and  their  English  and  Continental  sisters 
points  strongly  to  the  superiority  of  the  habits  of  hfe  of  the  latter.  The  vulnera- 
bility of  the  female  pelvic  organs  is  well  known,  and  most  of  the  dangers  attend- 
ing their  treatment  in  former  times  have  been  done  away  with  by  modern  aseptic 
technique.  The  causes  of  gynecological  disease  are  (i)  predisposing  and  (2) 
exciting.     Chronologically  considered,  the  first  predisposing  cause  is  heredity. 

Heredity. — The  untoward  results  of  this  factor  are  seen  either  in  the  direct 
transmission  from  mother  to  daughter  of  specific  physical  defects,  or  in  general 
ill  health  as  the  heritage  of  ill-conditioned  parents.     It  is  generally  accepted  that 

*  Rust's  "New  York  Penal  Code  and  Criminal  Procedure,"  1891,  chap,  v,  p  63,  sec 
303.  clause  4 


36  PHYSIOLOGY  OF  THE  FEMALE  GENITAL  ORGANS. 

the  children  of  parents  of  advanced  years  are  apt  to  be  less  vigorous  than  those  of 
younger  progenitors. 

Education. — This  has  a  powerful  influence  on  the  genital  functions.  Great 
concentration  in  study  uses  up  the  nerve  energy  of  the  body  and  leaves  the  uterus 
and  ovaries  without  their  legitimate  share.  Especially  does  close  application  to 
music  have  a  deleterious  effect  on  these  functions,  by  its  emotional  influences  and 
the  expenditure  of  nervous  energy  which  it  demands.  Hyperemia  of  the  pelvis, 
however  caused,  tends  to  produce  disease  of  its  contained  organs.  Sexual  excite- 
ment produced  either  through  mental  or  physical  influences — e.  g.,  the  observa- 
tion of  obscene  sights  or  pictures,  or  masturbation — is  also  a  cause. 

Mode  of  Life. — Lack  of  exercise  and  of  outdoor  air  is  a  fruitful  cause  of  disease 
and  poor  pelvic  circulation.  In  the  last  few  years  attention  has  been  called  to 
these  defects  in  the  life  of  the  average  American  girl,  and  athletic  sports,  com- 
paring favorably  with  those  of  men,  have  been  instituted.  Neglect  of  the  skin 
as  the  medium  for  so  much  of  the  vitiated  excretions  of  the  body  is  particularly 
noted  among  the  poorer  class  of  foreigners.  The  amount  and  kind  of  food  exer- 
cises an  important  influence  on  the  young  girl's  health.  A  common  habit,  which 
grows  stronger  with  every  repetition,  is  the  omission  of  breakfast.  Soda-water, 
ice-cream,  and  candy  are  most  harmful  if  taken  to  excess,  as  they  very  often  are. 
Indigestible  and  non-nutritious  foods  should  be  avoided.  All  these  factors  tend 
to  produce  anemia  and  general  ill  health.  Neglect  of  the  excretions  is  a  very 
common  fault  in  young  girls,  as  well  as  in  women,  and  especially  those  with 
gynecological  troubles.  The  bowels,  instead  of  moving  once  or  twice  a  day,  as 
they  should  normally,  are  evacuated  perhaps  once  a  week.  The  poisons  of  the 
waste  matter  are  absorbed  and  sapremia  results.  The  circulating  impurities 
show  themselves  in  the  anemic  appearance,  lack  of  energy,  headache,  and 
neuralgic  pains.-  Then,  again,  the  bladder  is  often  not  emptied  when  it  should 
be;  consequently  distention  and  displacement  of  the  uterus  by  the  enlarged 
bladder,  or  paralysis  of  that  organ,  or  cystitis  may  result.  Disregard  of  the 
menstrual  periods  causes  much  trouble.  Girls  during  these  periods  are  very  apt 
to  make  no  difference  in  their  manner  of  life  from  that  at  any  other  time. 
Oftentimes  violent  exercise  and  exposure  at  these  periods  bring  on  serious  con- 
sequences. 

Dress. — The  manner  of  dressing  has  much  to  do  with  health  or  disease ;  it  is 
especially  faulty  amongst  women.  Tight  garments  for  any  part  are  most  inju- 
rious. The  disproportionate  arrangement  of  clothes  as  to  the  warmth  they 
afford  is  injurious;  for  instance,  when  the  lower  abdomen  is  not  sufficiently  pro- 
tected. Incorrect  corsets  exert  a  most  baneful  effect  on  the  female  organism. 
The  old-fashioned  garment,  even  when  worn  loose,  exerts  a  pressure  of  thirty 
pounds  (Fig.  36).  The  abdomen  suffers  from  this  more  than  the  thorax.  There 
is  a  thinning  and  weakening  of  the  abdominal  wall,  which  becomes  relaxed  and 
pushed  forward,  in  the  upright  position,  by  the  liver  and  intestines.  In  the  sitting 
posture,  the  pressure  exerted  by  the  abdominal  wall,  which  should  be  backward 
against  the  spine,  is  exerted  downward  toward  the  pelvis,  and  causes  bulging  of 
the  vulva  even  to  the  extent  of  half  an  inch  (1.27  cm.).  Corsets  made  to  sup- 
port the  lower  abdomen  have  not  these  objections  (Fig.  37).  High  heels  should 
be  avoided,  for  when  they  are  worn,  especially  by  the  young,  whose  bones  and 
articulations  are  soft  and  pliable,  they  not  only  distort  the  foot  but  often  en- 
gender other  troubles,  such  as  neuralgic  pains  in  the  legs,  alterations  in  the  shape 
of  the  pelvis,  and  curvature  of  the  spine.  Ordinary  social  pleasures  entailing 
late  hours  have  a  very  bad  effect  on  a  girl's  nervous  organization. 

Sexual  Life. — Normal  sexual  intercourse,  even  when  frequent,  is  not  apt  to 


HYGIENE  OF  THE  SEXUAL  FUNCTIONS. 


37 


injure  a  healthy  woman.  But  irregularities  indulged  in  will  bring  in  their  train 
many  complaints.  Marriage,  if  pelvic  disease  exists,  is  often  attended  with  dire 
results,  and  causes  much  misery  to  both  husband  and  wife.  The  growth  of  fibro- 
mata seems  especially  active  in  the  uteri  of  unmarried  women  and  in  those  who 
have  never  borne  children.  It  would  seem  that  the  energies  of  that  organ,  which 
are  normally  applied  to  the  formation  of  a  child,  being  deprived  of  that  object, 
•  are  free  to  take  part  in  the  production  of  a  new  growth. 

The  Prevention  of  Reproduction. — The  act  of  reproduction   may  be  set  at 
naught  in  a  twofold  manner:  (i)  By  conditions  which  prevent  the  union  of  the 


Fig.  36. — Corset  Improperly  Titted,  so 
THAT  Abdominal  Contents  are  Pushed 
Downward  and  Backward,  thus  Fa- 
voring Posterior  Uterine  Displace- 
ments. Note  the  unnatural  pressure 
upon  the  breasts. — (Photographed  from 
life.) 


Fig.  37. — Properly  Fitting  Corset.  Hy- 
pogastrium  Supported  from  Below 
Upward.  Breasts  Free  and  only 
their   Lower  Portions  Supported. — 

(Photographed  from  life.) 


reproductive  units,  and  (2)  by  death  of  the  embryo  which  results  from  the  union 
of  these  units. 

I.  Non-impregnation. — When  non-impregnation  comes  about  solely  through 
conscious  efforts  of  the  participants,  we  have  a  condition  of  affairs  known  as 
artificial  sterility,  a  subject  which  has  a  distinct  obstetrical  significance,  because 
in  order  to  save  the  Hves  of  certain  women,  and  at  the  same  time  to  avoid  feticide, 
it  is  justifiable  to  prohibit  impregnation.  Unless  either  the  life  or  the  health  of 
the  woman  is  certain  to  be  wrecked  by  bearing  a  child,  or  unless  she  is  incapable 
of  giving  birth  to  a  normal  living  child,  the  prevention  of  impregnation  is  justly 
regarded  as  a  violation  of  the  moral  law,  an  injury  to  the  State,  and  to  a  certain 
extent  a  detriment  to  the  health  of  the  participants.     Technically,  at  least,  it  is  a 


38  PHYSIOLOGY   OF  THE  FEMALE  GENITAL   ORGANS. 

violation  of  the  criminal  code,  the  various  contrivances  used  for  the  prevention 
of  conception  being  regarded  as  contraband.     A  sharp  distinction  should  there- 
fore be  made  between  artificial  sterility  which  is  practised  to  save  the  more  ' 
valuable  life,  and  that  which  simply  seeks  to  prevent  reproduction  in  itself. 

Therapeutic  Prevention. — This  expression  signifies  the  prevention  of  impreg- 
nation in  cases  in  which  the  reproduction  of  a  healthy,  living  child  is  quite  impos- 
sible, or  if  possible  would  mean  either  the  death  or  permanent  invalidism  of  the^ 
mother. 

Indications. — These  comprise:  (i)  General  conditions  in  the  mother  which 
are  likely  to  be  transmitted  to  the  child — syphilis,  the  tuberculous  dyscrasia, 
insanity,  epilepsy.  (2)  General  conditions  in  the  mother  which  would  be  aggra- 
vated to  such  an  extent  by  reproduction  that  her  death  would  be  determined,  or, 
if  inevitable  in  any  case,  greatly  accelerated — heart  disease,  tuberculosis,  cancer, 
nephritis,  diabetes,  etc.  (3)  Conditions  in  the  mother  which,  by  producing 
extreme  dystocia,  would  make  Caesarean  section  the  only  route  by  which  the 
child  could  be  born — high  degrees  of  contracted  pelvis,  obstruction  of  the  birth 
tract  by  inoperable  tumors. 

Management. — In  the  case  of  a  woman  who  furnishes  any  of  the  indications 
just  enumerated,  it  is  the  duty  of  the  physician  to  inform  the  patient  and  her 
husband  of  all  the  consequences  of  impregnation  under  the  circumstances.  If 
the  matter  is  left  to  him  to  decide,  he  must  insist  that  conception  shall  not  occur. 
Much  further  than  this  he  can  hardly  go.  Realizing  that  cohabitation  without 
intercourse  is  a  condition  difficult  to  realize,  he  may  suggest  a  separation,  tem- 
porary or  not.  If  this  is  refused,  coitus  might  be  permitted  during  the  so-called 
agenetic  period  of  the  intermenstrual  cycle  (from  the  seventeenth  to  the  twenty- 
fourth  day  after  cessation  of  a  period).  The  married  pair  should  be  informed 
that  this  precaution  simply  diminishes  the  risk,  and  that  if  the  lS,tter  is  assumed, 
impregnation,  if  it  occur,  will  necessitate  interruption  of  the  pregnancy,  which 
will  submit  the  mother  to  more  or  less  danger,  hardship,  expense,  etc.  If  the 
matter  is  left  to  the  physician,  he  can  hardly  sanction  coitus  under  any  circum- 
stances. Sooner  or  later  the  question  will  arise  as  to  the  use  of  so-called  illegiti- 
mate measures  of  preventing  conception.  If  asked  the  objections  to  these,  he 
must  take  the  stand  that  every  one  of  these  preventive  measures  constitutes  an 
abuse  of  a  normal  function.  The  coitus  interruptus,  coitus  reservatus,  simple  or 
antiseptic  douching  after  coitus,  wearing  of  coverings  for  the  penis  or  obturators 
for  the  uterus,  etc.,  are  all  unphysiological  and  many  of  them  untrustworthy.  A 
physician  can  never  sanction  anything  which  is  frankly  unphysiological,  and 
should  explain  to  his  patients  that  the  act.  of  intercourse  consists  in  three  distinct 
stages:  (i)  The  male  organ  becomes  completely  rigid,  passing  from  a  state  of 
flaccidity  into  erection.  (2)  The  second  stage  comprises  intromission,  friction, 
and  the  orgasm  or  crisis.  (3)  The  act  of  copulation  is  not  concluded  by  the 
orgasm.  The  penis,  therefore,  should  not  be  withdrawn  at  once,  but  allowed  to 
remain  until  the  gradual  subsidence  of  the  erection  leaves  it  in  its  original  flaccid 
state.  This  final  stage  of  copulation  undoubtedly  plays  an  important  role  in 
impregnation,  and  if  it  is  shortened  or  omitted,  the  consequences  appear  to  be 
unpleasantly  felt  by  both  sexes.  In  other  words,  withdraw^al  of  the  penis 
immediately  after  the  orgasm  is  virtually  a  coitus  interruptus.  It  is  character- 
istic of  the  various  illegitimate  measures  for  preventing  conception  that  all  of 
them  interfere  with  the  second  or  third  stage  of  coitus.  The  consequences  to 
the  woman  of  these  illegitimate  practices  are  in  part:  (i)  An  unnatural  local 
congestion  which  leads  to  oophoritis,  endometritis,  leucorrhea,  dysmenorrhea, 
sterility,  metrorrhagia,  and  cancer  of  the  uterus;  (2)  neuroses  of  various  kinds, 


HYGIENE  OF  THE  SEXUAL  FUNCTIONS.  39 

spinal  irritation,  neurasthenia,  etc.  In  the  man  the  consequences  are  similar  in 
character,  with  the  addition  of  dissatisfaction  with  imperfect  coitus  with  his 
wife,  which  often  foments  dislike,  unfaithfulness,  marital  infelicity,  and  divorce. 
If  impregnation  is  actually  contraindicated  in  a  given  case,  the  practitioner  can- 
not recommend  any  of  the  illegitimate  modes  of  prevention  of  conception 
because  they  are  either  harmful,  or  untrustworthy,  or  both.  There  is,  however, 
one  course  possible,  which  may  be  recommended  as  both  safe  and  efficacious, 
and  one  which  can  hardly  be  abused.  That  is,  obhteration  of  the  Fallopian 
tubes  for  a  short  extent  by  the  vaginal  route. 

This  course  is  unobjectionable  in  theory  from  any  standpoint;  yet  I  fear  it 
hardly  constitutes  a  solution  to  the  problem. 

2.  Interruption  op  Pregnancy. — After  pregnancy  has  begun  it  may  be  in- 
terrupted by  the  natural  death  of  the  fetus  from  disease,  trauma,  etc.  This  is  con- 
sidered under  the  heads  of  death  of  the  fetus,  abortion,  etc.  (Part  III).  Preg- 
nancy intentionally  ended  is  feticide.  Criminal  feticide  is  the  destruction  of  fetal 
life  for  no  other  reason  than  to  avoid  child-birth.  This  is  considered  under  the 
head  of  criminal  abortion  (Part  III).  Therapeutic  feticide,  on  the  contrary,  con- 
sists in  taking  the  fetal  life  when  non-interference  with  pregnancy  would  result 
in  the  death  or  permanent  invalidism  of  the  mother,  or  the  birth  of  an  abnormal 
unit  of  society.  The  subject  of  therapeutic  feticide  is  considered  under  "  Ob- 
stetric Operations  "  (Part  X). 

Child-birth. — Child-birth  not  infrequently  is  the  origin  of  disease  of  the  pelvic 
organs,  which  hinders  or  prevents  their  normal  functions.  These  troubles  may  or 
may  not  result  from  improper  medicinal  or  surgical  treatment.  Abortion  is  a 
fruitful  cause  of  pelvic  trouble.  Puerperse  should  receive  the  most  careful 
attention,  and  should  be  kept  in  bed  till  the  uterus  has  contracted  back  into  the 
pelvis.  In  order  to  avoid  the  perils  of  gonorrheal  and  syphilitic  infection,  these 
subjects  are  now  receiving  like  attention  with  tuberculosis.  The  application  of 
the  general  principles  of  aseptic  midwifery  and  early  operative  measures  in  case 
of  delayed  labor,  with  immediate  surgical  attention  given  to  lesions  of  the  soft 
parts,  are  doing  much  to  prevent  the  frequent  pelvic  troubles  so  common  in 
former  years. . 

Climacteric. — The  climacteric,  although  a  physiological  process,  is  a  period 
during  which  various  diseases  may  show  themselves.  Nervous  phenomena  are 
among  the  most  common  disturbances.  The  most  serious  occurrence  is  the 
appearance  of  carcinoma,  either  in  the  uterus  or  in  the  breast.  During  this 
period  the  bowels  should  be  kept  open.  Cold  bathing  followed  by  brisk  rubbing, 
and  lukewarm  baths  taken  at  intervals  of  a  few  days,  tend  to  calm  the  nerves. 
The  diet  should  be  carefully  supervised.  The  patient  should  be  supported  men- 
tally and  encouraged  by  a  favorable  prognosis.  In  case  of  hemorrhage,  it 
should  be  checked  just  as  in  ordinary  cases. 

Cancer. — There  is  little  possible  prophylaxis  at  present  for  malignant  disease 
of  the  pelvic  organs,  but  there  is  hope  for  the  future.  As.  soon  as  the  true  cause 
of  cancer  is  discovered,  some  method  of  preventing  or  at  least  arresting  its 
progress  will  present  itself. 

Family  Physician. — The  family  physician  should  be  the  guide  of  the  child 
from  infancy  through  the  various  stages  of  life  up  to  womanhood.  He  should 
instruct  not  only  the  girl,  but  her  mother  also,  in  regard  to  the  importance  of  the 
sexual  organs,  their  functions,  and  their  proper  care.  The  generative  organs  are 
the  last  to  develop,  and  when  the  girl  is  deficient  in  vitality  these  organs  are  the 
first  to  suffer,  for  when  undeveloped  they  are  most  prone  to  disease. 


PART   TWO, 
Physiological  Pregnancy* 


PHENOMENA  PRODUCED  BY  PREGNANCY  WITHIN  THE  UTERUS. 
(Page  41.)— The  Ovum;  Maturation;  Fertilization;  Primitive  Chorion; 
Deciduse;  Segmentation;  Qerm=layers;  Primitive  Organs;  Origin  of  Mem- 
branes; Amnion;  Allantois;  Chorion;  Placenta;  Umbilical  Cord;  Nutrition 
and  Metabolism  of  the  Ovum,  Embryo,  and  Fetus ;  Characteristics  during 
the  Several  Lunar  Months ;  Evolution  and  Determination  of  Sex. 

II.  PHENOMENA  PRODUCED  BY  PREGNANCY  IN  THE  MATERNAL  OR- 

GANISM. (Page  89.) — Local  Phenomena  in  the  Genital  Tract,  Adnexa, 
Pelvis,  and  Breasts;  General  Phenomena  in  the  Digestive  System,  Heart, 
Lungs,  Liver,  Nervous  System,  Blood,  Urine,  Skin,  etc. 

III.  THE  DIAGNOSIS  OF  PREGNANCY.     (Page  119.) 

IV.  THE  DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.     (Page  132.) 
V.  FEIGNED  PREGNANCY— PSEUDOCYESIS.     (Page  138.) 

VI.  UNCONSCIOUS  PREGNANCY.     (Page  139.) 

VII.  MULTIPLE  PREGNANCY.     (Page  140.) 

VIII.  THE  DURATION  OF  PREGNANCY.     (Page  144.) 

IX.  CALCULATING  THE  DATE  OF  CONFINEMENT.     (Page  146.) 

X.  THE  EXAMINATION  OF  PREGNANCY.  (Page  148.)— Obstetric  Asepsis  of 
Patient  and  Physician ;  Objects,  External  or  Abdominal ;  External  Pelvi- 
metry; Internal  or  Vaginal;  Internal  Pelvimetry;  Rontgen  Pelvimetry; 
Pelvigraphy;  Indirect  Pelvimetry;  Cliseometry;  Cephalometry. 

XI.  THE  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY.  (Page  184.)  — 
Prophylaxis;  Exercise;  Diet;  Drink;  Bowels;  Fresh  Air;  Care  of  Skin, 
Clothing,  Breasts ;  Mental  Condition ;  Examination  of  Urine ;  Sexual 
Intercourse. 


I.   THE  PHENOMENA   PRODUCED    BY    PREGNANCY   IN  THE 

UTERUS.     THE   DEVELOPMENT   OF  THE  OVUM, 

EMBRYO,   FETUS,   FETAL  MEMBRANES, 

AND  FETAL  STRUCTURES. 

Introduction. — Pregnancy  begins  with  conception  and  normally  ends  with 
labor  at  the  fortieth  week.  If  no  complications  arise  during  this  time,  we  have 
a  physiological  pregnancy  (Part  II).  On  the  other  hand,  various  accidents  may 
bring  about  a  pathological  pregnancy  (Part  III). 

A  nulliparous  woman,  or  a  nullipara,  is  one  who  has  never  borne  a  child, 
and  the  condition  is  one  of  nulliparity; 

A  primigravidous  woman,  or  a  primigravida  (or  primipara),  is  one  who  is 
pregnant  for  the  first  time,  and  in  subsequent  pregnancies  she  is  known  as  a 
multigravidous  woman  or  a  midtigravida  (or  multipara).  Different  degrees 
of  gravidity  or  parity  are  usually  designated  by  the  Roman  numerals,  thus: 
Ipara,  a  woman  in  her  first  pregnancy;  Ilpara,  one  in  her  second  pregnancy; 
Illpara,  IVpara,  Vpara,  etc. 

In  the  following  review  of  the  subject  of  embryology,  emphasis  is  placed  upon  the 
growth  of  the  embryo,  fetal  membranes,  and  fetal  circulation — facts  which  bear  most  directly 
upon  the  subject  of  obstetrics.  For  a  full  consideration  of  the  subject  special  works  on 
embryology  should  be  consulted.  Among  these,  Minot's  discussions  of  difficult  points  are 
valuable,  while  the  most  recent  book  with  an  almost  exclusive  bearing  upon  human  embry- 
ology is  KoUmann's  "  Entwickelungsgeschichte  der  Menschen."  The  embryological  part  of 
Quain's  "Anatomy"  and  Hertwig-Mark's  "Embryology"  also  give  excellent  accounts  of 
the  subject.  For  the  latest  information  one  must  refer  to  the  monographs  which  are  appear- 
ing in  scientific  periodicals.  His's  monumental  work*  is 
the  source  of  the  greater  portion  of  the  accurate  informa- 
tion on  the  sub j  ect  of  human  embryology.  The  phenomena 
of  the  development  of  the  human  being  in  its  earliest  stages 
have  not  been  adequately  worked  out;  hence  the  gaps  in 
knowledge  are  usually  filled  in  by  statements  from  com- 
parative embryology.  We  shall  endeavor  to  differentiate 
what  is  known  of  human  development  from  that  which  is  ■  y,-^ 

inferential.  \\|x 

The  Ovum. — At  birth  the  ovary  of  a  child  is  ''^'^^-,  ua 

believed  to  contain  the  maximum  number  of  ova,  "^   ~  -or~  "-' 

estimated  as  high  as  70,000.     These  primordial  ova      Fig.     38. — Primitive    Folli- 

are   typical,  spherical    cells    containing  a  nucleus         ^^  ^^^^l.  "^"^  ^^J^'^V^^^t 
.  ,     •'^        '     ^  .  ,*',,.   .„.  Woman  Thirty-two  Years 

with  a  membrane  and  one  or  several  nucleoli  (rig.  Qld.  th,  Connective-tissue 
38).  They  are  arranged  in  so-called  egg-tubes  of  layer;  theca  folliculi ;  /,  epi- 
Pfluger  and  egg-nests  (Fig.  39),  which  extend  for  t^f^^i',  '^^^S. 
some  distance  into  the  body  of  the  ovary.  By  or  germinative  vesicle. — 
the  gradual  ingrowth  of  vascular  connective- tissue  {Ajter  W.  Nagel.) 
between  the  individuals  of  the  tubes  and  nests  the 

ova  are  separated  and  become  entirely  surrounded  by  a  connective-tissue  sheath 
the  theca  folliculi.     Thus  are  formed  the  primitive  follicles  which  at  a  later  stage 

*  "Anatomie  menschlicher  Embryonen,"  18S0-18S5. 
41 


^^ 

^^f^ 

■^ 

■J-V^ 

v^ 

t 

'Ov 

42 


PHYSIOLOGICAL  PREGNANCY. 


of  development  are  known  as  Graafian  follicles  (Fig.  i).  As  the  ova  develop 
they  increase  in  size  until  at  maturity  they  are  about  y-^  inch  (0.2  mm.)  in 
diameter,  surrounded  by  a  porous  membrane,  the  zona  pellucida  or  radiata;  this 
in  turn  is  surrounded  by  a  several-layered  follicular  epithelium  known  as  the 
corona  radiata.  A  cell  membrane  limits  the  ovum  proper,  between  which  and 
the  zona  pellucida  there  exists  a  narrow  fissure  known  as  the  perivitelline  space 
The  cell  body,  or  vitellus,  is  protoplasmic  and  contains  a  few  granules  of  food- 
yolk  similar  to  that  which  forms  so  marked  a  feature  of  the  hen's  egg.  On 
account  of  this  small  amount  of  food-yolk,  or  deutoplasm,  the  mammalian  egg 
is  said  to  be  alecithal  (without  yolk),  in  contradistinction  to  telolecithal  eggs, 
as  best  exemplified  by  Amphibia  and  birds,  where  the  nutritive  yolk  is  massed 


J^S       KE        PS 


Fig.  40. — Full-grown  Human  Ovum  before 
Maturation.  A  spherical  cell  with  nucleus, 
nucleolus,  and  yolk  granules,  z.p..  Zona  pel- 
lucida; y.  ox  v.,  yolk  or  vitellus;  g.v.,  germinal 
vesicle  with  nucleolus;  cr.,  corona  radiata;  pz., 
protoplasmic  zone  of  ovum;  p.s.,  perivitelline 
space. — (After  Nagel.) 


Fig.  39. — Development  of  Graafian 
Follicle  of  Mammals.  D,  Cumulus 
oophorus;  Ei,  ripe  egg  with  its  germ  i- 
native  vesicle  and  germinative  spot 
(K);  Ke,  germinal  epithelium;  Lf, 
liquor  folliculi;  Mg,  stratum  granu- 
losum;  Mp,  membrana  pellucida ;  Ps, 
Pfluger's  tubes;  5,  fissure  between 
follicular  cells  {G)  and  cumulus  oopho- 
rus; 5o,  connective-tissue  stroma  with 
blood-vessels  (g);  Tf,  theca  folliculi; 
V,  V,  primitive  follicles. — {After  Wie- 
dersheim.) 

at  one  pole;  and  centrolecithal  eggs,  as  exemplified  by  Arthropods,  where  the 
deutoplasm  has  a  central  position. 

The  nucleus  becomes  somewhat  eccentrically  placed  and  contains  a  conspi- 
cuous nucleolus  (Figs,  i  and  40).  The  whole  ovum  is  encapsuled  by  the  Graaf- 
ian follicle.  The  follicles  are  scattered  at  different  levels  throughout  the  stroma 
of  the  ovary  (compare  Ovulation,  page  17). 

Maturation  of  the  Ovum  and  Zoosperm. — In  many  of  the  lower  animals 
a  process  called  maturation  of  the  ovum  has  been  observed,  whereby  the  nucleus 
migrates  toward  the  surface  and  by  an  active  process  of  division  throws  off 
a  part  of  its  substance  in  the  form  of  polar  globules,  the  part  remaining  in  the 
cell  being  called  the  female  pronucleus  or  egg  nucleus. 


PHYSIOLOGICAL   PREGNANCY, 


43 


Polar  bodies  in  different  stages  of  development  have  been  found  in  the  eggs 
of  mammals  (Figs.  41  and  42),  and  we  may  reasonably  infer  that  a  similar  pro- 
cess transpires  in  the  human  ovum.  As  the  result  of  a  somewhat  analogous 
process  of  maturation  and  division,  the  zoosperm  or  mature  male  element  (Fig. 


Fig.  41. — Formation  of  Polar  Globules, 
Mouse.  Showing  the  nucleus  of  the 
ovum  dividing  to  form  the  first  polar 
globule,  p.g.,  and  at  the  right  a  zoo- 
sperm,  s,  which  has  entered  at  the  pro- 
jecting portion. — (After  Sobotta.) 


Fro.  42. — Fertilization  in  the  Mouse 
Showing  an  ovum  with  two  polar  globules 
and  the  male  and  female  pronuclei  about 
to  unite;  g.  s.,  achromatic  spindle.^ 
(Ajier  Sohotta.) 


'y^ 


Fig.  43. — Ovum  of  White 
Mouse.  First  segmen- 
tation spindle  with  the 
chromosomes  of  the  pro- 
nuclei still  forming  two 
distinct  groups.  X  1500 
diams. — {After  Sohotta.) 


Fig.  44. — Ovum  of  White 
Mouse.  First  segmenta- 
tion spindle  with  equa- 
torial plate  of  chromo- 
somes. X  1500  diams. — 
{After  Sobotta.) 


Fig.  45. — Ovum  of  White 
Mouse.  First  segmenta- 
tion spindle.  The  chro- 
mosomes have  divided 
and  migrated  toward  the 
poles  of  the  spindle,  form- 
ing two  groups.  X  1500 
diams. — {After  Sobotta.) 


8)  contains  a  nucleus, — the  male  pronucleus,  or  sperm  nucleus, — which  repre- 
sents only  a  part  of  the  original  nucleus  from  which  it  was  derived. 

Fertilization  or  Impregnation. — When  the  two  sexual  elements  come  in 
contact  in  the  upper  part  of  the  Fallopian  tube,  the  zoosperm  enters  the  ovum, 
where  its    body  becomes    indistinguishable  (Fig.  42),  and  a  union  of  the  two 


44 


PHYSIOLOGICAL  PREGNANCY. 


pronuclei  takes  place.  This  is  considered  the  essential  step  in  fertiHzation, 
the  union  giving  rise  to  a  new  nucleus  called  the  segmentation  nucleus.  In  the 
ovum  of  the  white  mouse,  according  to  Sobotta,  the  pronuclei  never  actually  fuse 
to  form  a  membranate  segmentation  nucleus.  Here  the  pronuclei  lie  first  in  close 
apposition  and  are  then  separated  by  the  formation  of  the  achromatic  spindle 
(Fig.  42). 

The  pronuclei  now  break  up  into  chromosomes  and  arrange  themselves  first 
into  two  groups  about  the  spindle  (Fig.  43)  and  then  into  an  equatorial  plate  (Fig. 
44).  At  this  stage  there  occurs  a  longitudinal  splitting  of  the  chromosomes  and  a 
consequent  doubling  of  their  original  number.    The  chromosomes  next  draw  apart 

toward  the  two  poles  of  the  spindle 
(Fig.  45),  where,  after  the  completion 
of  the  first  segmentation,  they  give  rise 
to  the  nuclei  of  the  resulting  cells.  It 
is  now  believed  that  a  similar  process 
of  fertilization  takes  place  in  all  mam- 
malian ova.  Facts  of  this  sort  have 
great  bearing  upon  theories    of  heredity, 


■)•■■■ 


Fig.  46. — Transverse  Section  of  the 
Uterus  from  a  Six-months'  Fetus 
AT  THE  Level  of  the  Internal  Os. 
I,  Cylindrical  ciliated  epithelium;  2, 
connective-tissue  stroma  of  mucous 
membrane  containing  blood-vessels; 
3,  muscular  layer  with  arteries;  4,  sub- 
serous connective  tissue;  5,  peritoneal 
endothelium;  6,  intraligamentary 
connective  tissue,  containing  main 
branches  of  uterine  artery. — {Schaej- 
jer.) 


Fig.  47. — Uterus  and  Ovum  at  Seventh  or 
Eighth  Day.  Section  through  Fig.  48. 
o,  Decidua  vera;  b,  d,  decidua  reflexa;  c, 
ovum;  o.i.,  internal  os. — {Leopold.) 


because  it  is  evident  that  the  actual  sub- 
stance derived  from  both  parents  goes 
to  form  the  new  individual  and  appar- 
ently is  distributed  by  subsequent  nuclear 
division  to  every  portion  of  the  body  (see 
Impregnation,  page  29). 
Primitive  Chorion. — During  its  passage  through  the  Fallopian  tube  the  ovum 
derives  more  or  less  nourishment  from  the  parts  by  which  it  is  surrounded. 
This  is  accomplished  at  a  very  early  period  by  the  formation  upon  all  of  the 
extra-embryonic  somatopleure  of  a  growth  of  delicate  villi  which  give  to  the 
ovum  even  at  this  time  a  shaggy  appearance.  This  is  the  primitive  chorion, 
and  the  whole  ovum  at  this  time  is  called  the  chorionic  vesicle. 

The  Deciduae. — The  uterus  prepares  for  the  reception  of  the  fertilized  ovum 
by  the  premenstrual  swelling  of  its  mucosa  which  forms  a  pulpy  nidus  for  its 
new  occupant.  If  the  fertilized  ovum  does  not  then  appear,  menstruation 
takes  place.    If  the  fertilized  ovum  remains  in  the  genital  tract,  then  the  uterine 


PHYSIOLOGICAL  PREGNANCY. 


45 


mucosa  undergoes  changes  by  which  it  is  converted  into  decidua.  That  formed 
in  pregnancy  is  called  decidua  gravidilaiis.  The  normal  uterine  mucosa  is  thin, 
averaging  from  0.039  to  0.117  inch  (i  to  3  mm.)  in  thickness.  Its  most  marked 
change  in  pregnancy  is  the  increase  in  this  dimension,  for  in  this  condition  it 
often  attains  -g-  inch  (i  cm.)  in  thickness.  It  is  very  vascular,  soft  and  velvety 
in  consistence,  and  its  surface  is  wavy  or  undulating,  studded  with  depressions 
which  correspond  to  the  openings  of  glands.  With  the  beginning  of  pregnancy 
the  decidua  comprises  three  parts :  ( i )  Decidua  vera  is  the  hypertrophied  mucous 
membrane  of  the  entire  uterus  (Figs.  47,  48,  and  49).  It  atrophies  in  the 
last  third  of  pregnancy  and  is  cast  off  in  part  with  the  membranes  at  labor  and 
in  part  with  the  lochia.  (2)  Decidua  serotina,  placental  serotina  or  decidua 
basilis,  is  that  part  of  the  decidua  vera  upon  which  the  ovum  is  embedded 
and  which  subsequently  takes  part  in  the  formation  of  the  placenta  (Fig.  47). 
(3)  Decidua  reflexa,  circumfiexa  or  capsularis,  or  epichorial  decidua,  is  not,  as 
its  original  name  indicates,  reflected,  but  is  formed  by  growth  of  the  uterine 
tissues  over  the  ovum  till  they  meet  above  its  surface  (Figs.  47  and  49).      This 


Fig.  48. — Uterus  and   Ovum  at  Seventh  or  Eighth  Day,  showing  Decidua  Vera. 
o.i,  Internal  os;  a,  uterine  wall. — (Leopold.) 


process  of  reflexion  is  nearly  completed  in  the  youngest  human  ovum,  Peters 's 
(Fig.  51),  and  is  quite  finished  in  from  eight  to  twelve  days  after  the  migration 
of  the  ovum  into  the  uterus.  The  capsule  grows  with  the  increase  of  the  ovum 
until  the  second  month,  when  it  begins  to  degenerate,  disappearing  entirely  by 
the  seventh  month  (Fig.  53). 

Theories  of  the  Origin  of  the  Decidua. — There  have  been  various  theories 
concerning  the  decidua.  In  1840  Weber  and  Sharpy  demonstrated  glands 
within  it  and  showed  it  to  be  a  hypertrophied  mucosa.  Friedlander's  ideas 
concerning  the  structure  of  the  decidua  are,  in  general,  correct.  He  found 
therein  glands  lined  by  high,  columnar,  ciliated  epit;helium.  The  decidua  vera 
comprises  two  layers;  the  upper  layer,  or  stratum  compactum,  consisting  of 
decidual  cells  with  gland  ducts  here  and  there,  while  the  attached  layer,  or 
stratum  spongiosum,  is  of  spongy  consistency,  and  made  up  of  a  few  decidual 


46 


PHYSIOLOGICAL  PREGNANCY. 


cells,  blood-vessels,  and  dilated  glands  or  cavities..    Friedlander  believed  that 
at  the  end  of  pregnancy  the  compact  layer  is  thrown  off;  while  there  is  left  the 


/ 


'..'^Si^  V5:>;/T(V 


Cih:: 


■  y^'^.'-z'r-^-^--^M^^^. 


Fig.  49. — Microscopic  Section  through  an  Ovum  in  Situ  at  the  Seventh  or  Eighth 
Day,  showing  Uterine  Wall,  Decidua  Vera  and  Reflexa. — (Leopold.) 


Fig    50. — Uterus  and  Ovu.m  at  Two  Weeks,      o,  Ovum;  d,  decidua  vera;  o.i.,  internal 

os;  5,  external  os. — (Leopold.) 


spongy  layer,  which  is  the  dilated,  irregular  surface  usually  seen.  It  is  now 
known  that  the  line  of  demarcation  is  somewhat  deeper  than  Friedlander  be- 
lieved.    His  work  has  been  verified  by  Leopold  and  Meinert. 


PHYSIOLOGICAL  PREGNANCY. 


47 


""'"    %^'0^^^^^S&iSi:f<if^^        .  :  .^  :  ■.,';;...  :.i-'/'^ 


j^    .V~^'^j^.r\-"VJ.      -i-.r^-     '■ 


Fig.  51. — Section  OF  Peters's  Ovum  IN  Situ.  y4m.c,  Amniotic  cavity;  WJac,  blood  lacuna; 
clol,  blood-clot  on  surface  of  the  uterus;  Cce,  extra-embryonic  ccelom;  Conn,  connective 
tissue  of  uterus;  Ec,  ectoderm  of  chorion;  Ep,  epithelium  of  uterus;  Mes,  mesoderm  of 
chorion;  Sh,  embryonic  shield;  Tro,  trophoblast;  Yi,  mesodermic  core  of  chorionic  villus; 
Yk,  cavity  of  yolk-sac. — {After  H.  Peters.) 


.       nnagl. 


'mr' 


•  ■  ^^^-Z 


^mp' 


m 


jSMSSk 


ii 


d'  W' 


'^&% 


FiG.  52. — Uterus  One  Month  Pregnant;  Portion  of  the  Compact  Layer  of  the 
Decidua  seen  in  Vertical  Section,  coagl,  Coagtilum  upon  the  surface;  d.  d' ,  decidual 
cells.      X  445  diams. — (Minot.) 


48 


PHYSIOLOGICAL  PREGNANCY. 


The  Decidual  Cell. — The  origin  of  the  decidual  cell,  discovered  by  Hegar 
and  Maier  about  i860,  though  variously  explained,  is  now  known  to  be  the 
connective-tissue  cell.  It  is  much  larger  than  the  cell  of  the  interglandular 
substance  and  is  often  very  irregular  in  shape.  The  hypertrophied  decidual 
cell  (Fig.  52)  resembles  the  epithelioid  cell  of  tuberculosis  and  the  lutein  cell. 
It  also  resembles  the  large  sarcoma  cell,  and,  according  to  Ruge,  is  the  physio- 
logical type  of  this  pathological  unit.  The  hypertrophied  decidua,  the  spongy 
layer  in  the  early  months  of  pregnancy,  may  look  like  malignant  adenoma. 

Formation. — The  formation  of  the  decidua  is  not  dependent  on  the  presence 
of  the  fertilized  ovum,  for  we  find  it  in  the  extrauterine  pregnancy.  This 
condition  is  not  absolutely  pathognomonic  of  pregnancy,  for  the  decidual  cell 
is  found  in  endometritis  and  membranous  dysmenorrhea,  in  which  latter  affec- 
tion a  cast  of  the  uterus  is  thrown  off.     The  development  of  the  decidual  cell 


Fig.  53. — Diagram  showing  the  Relations  of  the  Uterus,  Embryo,  and  Embryonic 
^Structures  at  the  Second  Month  of  Gestation. — (After  Allen  Thompson.) 


from  the  connective  tissue  of  the  stroma  of  the  uterus,  and  that  of  the  lutein 
cell  from  the  connective  tissue  surrounding  the  ovum,  are  analogous  processes. 
In  the  ovary  they  tide  over  the  reconstruction  period,  while  in  the  uterus  they 
help  to  form  the  placenta,  and  after  the  birth  of  the  child  they  are  cast  off. 

Disappearance. — The  decidua  vera  is  thickest  at  the  third  month  of  preg- 
nancy, after  which  it  steadily  becomes  thinner  (Figs.  105  and  137).  In  early 
pregnancy  the  ovum  does  not  completely  fill  the  uterine  cavity,  but  when  this 
comes  about  the  decidua  vera  is  compressed  and  begins  to  atrophy,  while  the 
decidua  reflexa  comes  into  closer  and  closer  contact  with  it,  until  about  the 
sixth  month,  at  which  time  the  two  deciduse  cannot  be  distinguished.  At  term 
the  vera  is  not  much  thicker  than  the  original  mucous  membr,ane.  Until  the 
period  of  fusion  of  these  two  parts  of  the  decidua,  the  interval  between  them 
is  filled  with  hydroperione,  a  mucous  liquid  much  like  the  liquor  amnii.      During 


SEGMENTATION. 


49 


the  later  months  of  pregnancy  the  decid.ua  undergoes  a  fatty  degeneration  that 
assists  in  loosening  its  attachment  to  the  uterus,  and,  as  already  stated,  the 
greater  part  of  this  membrane  is  cast  off  during  labor.  Its  remains  are  dis- 
charged with  the  lochia,  save  a  very  little  that  stays  behind  to  assist  in  the 
production  of  a  new  uterine -mucosa  (compare  Physiologic  Puerperium) 


Is.  - 


z.p. 


~i     P-b- 


Fig.  54. — Segmentation  of  a  Mammal,  Bat.  Two-celled  Stage.  Two  segmentation 
spheres  each  having  a  nucleus.  The  dark  bodies  are  yolk  granules,  s.s.,  Smaller 
segmentation  sphere;  l.s.,  larger  segmentation  sphere;  z.p.,  zona  pellucida;  p.b.,  polar 
globule. — {After  E.  van  Beneden.) 


Fig.  55. — Segmentation  of  the  Ovum, 
Rabbit.  Four-celled  Stage. — {After 
van  Beneden.) 


Fig.  56. — Segmentation  of  the  Ovum,  Rab- 
bit. Many-celled  or  Morula  Stage. 
Numerous  spermatozoa  lie  in  the  thick- 
ened egg  membrane. — {After  Bischoff.) 


Segmentation. — In  the  human  ovum  nothing  is  known  of  the  process  by 
which  a  single  cell  subdivides  into  many.  In  lower  vertebrates  and  several 
mammals  the  process  has  been  carefully  followed.  In  the  latter,  the  segmenta- 
tion-nucleus divides,  thus  forming  two  cells  which  again  divide.  These  four  again 
divide,  and  the  process  of  subdivision  is  continued  until  a  soHd  ball  of  cells  is 
4 


50 


PHYSIOLOGICAL  PREGNANCY. 


formed,  the  early  blastula  or  morula,  so  called  rom  its  resemblance  to  a  mulberry 
(Figs.  54,  55,  and  56).     In  Amphioxus  and  some  other  lower  forms  the  morula 


Fig.  57. — Segmentation  of  the  Ovum.  Sections  of  the  Ovum  of  the  Rabbit  During 
THE  Later  Stages  of  Segmentation,  showing  the  Formation  of  the  Blastodermic 
Vesicle,  a,  Showing  the  outer  layer  and  the  inner  cell  mass  before  the  formation  of  a 
cavity;  also  the  so-called  blastopore  * ;  b,  showing  the  cavity  formed  by  the  absorption 
of  liquid;  c,  enlarged  cavity;  d,  showing  the  cell  mass  forming  a  layer  at  one  side  of  the 
thinned  outer  or  Rauber's  layer;  ent.,  inner  mass  of  cells;  ect.,  outer  or  subzonal  layer. 
When  the  ovum  attaches  itself  to  the  uterine  wall,  this  laj^er  becomes  the  trophoblast; 
z.p.,  zona  pellucida. — {After  van  Beneden.) 


sec.c- 


Ky      l.TTL 


Fig.  58. — Formation  of  the  Blastodermic  Layers  in  the  Mole  in  Three  Successive 
Stages,  z,  Zona  pellucida;  ex.,  subzonal  epithelium  (ectoderm);  sec.c,  segmentation 
cavity;   hy.,  hypoblast;    i.m.,  inner  mass  of  cells. — (Minot.) 

by  further  division  of  its  cells  is  converted  into  a  blastula,  which  by  the  process 
of  invagination  at  the  vegetative  pole  becomes  a  gastrula  (Fig.  59). 

*  Minot  thinks  that  van  Beneden  erred  in  his  interpretation  of  the  interruption  in  the  outer 
or  subzonal  layer,  and  believes  that  it  is  really  a  continuous  layer  of  cells. 


SEGMENTATION. 


51 


Such  a  total  division  of  cells  is  called  holoblastic,  to  distinguish  it  from  mero- 
blastic  division,  or  such  as  takes  place  in  a  chick,  in  which  a  partial  division  of 
the  egg  occurs,  forming  a  disc-like  layer  of  cells  on  the  surface  of  a  large,  undivided 
yolk. 

Holoblastic  or  total  division  occurs  in  all  but  the  two  most  primitive  mam- 
mals, the  ornithorhynchus  and  echidna,  in  which  there  is  a  large  polar  yolk  mass 
which  does  not  divide  completely  into  cells.  The  discovery  of  the  latter  fact 
affords  a  key  to  the  apparently  anomalous  condition  of  the  higher  vertebrates, 
in  which  the  embryo  in  its  early  stages  of  development  resembles  very  closely 
that  of  reptiles  and  birds;  and  the  fetal  membranes  show  strict  correspondence 
in  form  and  function  to  those  of  the  latter.  The  method  of  development  and  the 
form  of  fetal  appendages  peculiar  to  reptiles  and  birds  is  consequent  upon  the 
large  mass  of  nutritive  yolk  contained  in  their  eggs.  The  fact  that  the  ova  of 
higher  mammals,  while  containing  little  or  no  yolk,  yet  in  their  development  fol- 
low along  the  lines  of  yolk-containing 
eggs,  is  explained  by  the  hypothesis  that 
they  have  descended  from  oviparous  an- 
cestors whose  eggs  were  rich  in  yolk. 


-■iT^X 


■<,^^:^^c. 


dg. 


'^■^%sj 


Fig.  59. — Formation  of  Gastrula,  Amphiox- 
us.  The  entoderm,  en.,  has  begun  to  in- 
vaginate,  making  the  segmentation  cavity, 
S.C.,  smaller;  e.c,  ectoderm. — {After  Hat- 
schek.) 


^'yoo] 


Fig.  60. — Formation  of  Gastrula  in  Am- 
PHioxus.  The  segmentation  cavity  has 
almost  disappeared  between  the  ecto- 
derm, ec,  and  the  invaginated  entoderm, 
en.,  which  lines  the  digestive  cavity,  d.g., 
or  enteron.  The  opening  of  the  latter  is 
the  original  oral  opening  or  blastopore, 
0.0.  A  single  mesodermic  cell,  m.c,  at 
the  left  at  the  union  of  the  ectoderm 
and  entoderm. — {After  Hatschek.) 


According  to  this  hypothesis,  Mono- 
tremes  and  Marsupials  are  the  connect- 
ing links  between  birds  and  mammals. 
In  the  evolution  of  viviparous  mammals 

the  membranes  which  were  formerly  of  service  in  development  within  egg  capsules 
and  in  the  presence  of  nutritive  yolk  now  become  adapted  for  intra-uterine  devel- 
opment where  nourishment  is  received  direct  from  the  maternal  organism.  In 
some  of  the  forms  observed,  the  cells  of  the  morula  are  not  uniform  in  appear- 
ance, larger  clear  cells  being  massed  at  one  pole,  smaller  dark  cells  at  the  other. 
The  clearer  cells  grow  and  divide  more  rapidly,  finally  forming  a  complete  en- 
velope except  at  one  point  (as  recorded  by  van  Beneden)  (Fig.  57),  surrounding 
the  smaller  cells.  As  the  morula  passes  by  the  action  of  the  ciliated  epithelium 
through  the  Fallopian  tubes  a  liquid  is  formed  between  the  two  kinds  of  cells 
which  increases  in  amount  until  there  is  produced  a  much  enlarged,  hollow  sphere 
of  flattened  cells,  within  which  and  attached  to  one  point  is  a  group  of  smaller 
elements  (Fig.  57).  The  former  cells  compose  the  subzonal  layer,  later,  some- 
times known  as  Rauber's  layer;  the  latter  are  known  as  the  inner  cell  mass  and 


52 


PH  YSIOLOGICA  L  PREGNA  NC  Y. 


eventually   give   rise   to   the   major  part   of    the    ectoderm    and   the    entire 
entoderm. 

Formation  of  Germ-layers. — By  reason  of  the  control  of  conditions,  which 


Fig.  6i. — Germ-disc  of  an  Embryo  Rab- 
bit.— (After  E.  van  Beneden.)  pr,  Primi- 
tive streak;  kf,  head  process;  hk,  Hen- 
sen's  node;  en,  canalis  neurentericus. 
— {Hertwig-Mark.) 


fh 


Fig.  62. — Longitudinal  (Sagittal)    Sec- 
tion   THROUGH    AN    EgG    OF   TriTON   AT 

THE  Beginning  of  Gastrulation.  ak 
Outer  germ-layer;  ik,  inner  germ -layer; 
jh,  cleavage-cavity;  vd,  coelenteron;  w, 
blastopore;  ci2,  yolk-cells;  dl  and  vl,  dor- 
sal and  ventral  lips  of  the  blastopore. — 
{Hertwig-Mark . ) 


JVC      CH 


BH  L'M 


PJV 


\.5i=- 


Fig.  63. — Sagittal  Section  of  Frog  Embryo  showing  the  Three  Layers.  The  blasto- 
pore now  becomes  the  proctodeal  opening  and  the  neurenteric  canal  joining  enteron 
with  neural  canal. — {After  Gotte.) 

BF,  Fore-brain;  BH,  hind-brain;  BM,  mid-brain;  CH,  notochord;  M,  mesoblast;  NC, 
cavity  of  neural  tube;  NT,  neurenteric  canal;  PN,  pineal  body;  PT,  point  where 
future  mouth  arises;  TI,  intestinal  region  of  mesenteron;  TP,  pharyngeal  region  of 
mesenteron;   J/,  proctodeal  aperture ;  VK,  liver;   Y",  yolk-cells. 


is  possible  in  that  animal,  the  formation  of  germ-layers  has  been  more  fully 
and  frequently  studied  in  the  chick  than  in  any  other  species.  The  following 
changes,  however,  have  been  taken  from  the  embryology  of  the  rabbit,  which 
is  tolerably  well  understood,  because  this  mammal  naturally  has  more  resem- 


FORMATION  OF  GERM-LAYERS. 


53 


blance  to  man.     The  concentrated  mass  of  cells  above  described  at  the  pole 
of  the   ovum   flattens   out  into   a  disc   called   the   blastoderm,  which  is  seen  to 


y.s. 


a.s. 
I.e. 

Fig.  64. — Section  THROUGH  Early  Human  Ovum.  X  24.  c?.^.,  Embryonic  disc;  e(;.,  ecto- 
derm; m.,  mesoderm;  y.s.,  yolk-sac;  c,  chorion;  ,am.,  amnion;  a.s.,  allantoic  stalk; 
a.c,  allantoic  canal. — {After  Graf  Spee.) 

consist  of  two  kinds  of  elements  (Fig.  58,  c),  with  two  layers  next  to  the  outer 

sphere  of  flattened  cells;  and  more  or  less  continuous  with  it,  which  together 

are  regarded  as  the  ectoderm.     The  cells 

which  complete   the  sphere  are  called, 

from    their  discoverer,  Rauber's    layer, 

and  in  the  rabbit  they   disappear   (see 

Membranes). 

There  are  also  cells  lying  next  to  the 
cavity  which  form  the  entoderm,.  This 
two-layered  germ,  though  arising  in  a 
much  modified  manner,  is  properly  com- 
parable with  the  two-layered  or  gastrula 
stage  of  the  amphioxus  (Fig.  60),  and 
the  cavity  is  also  called  the  segm-entation 
cavity.*  The  blastoderm  of  the  rabbit, 
as  seen  from  above,  soon  takes  the  form 
of  a  shield,  in  the  mid-line  of  which  is 
seen  the  primitive  streak  (Fig.  61).  In 
section  this  is  found  to  be  a  thickened 
cord  of  cells  in  which  ectoderm  and  en- 
toderm fuse,  and  from  the  junction  of 
which  a  third  layer,  called  the  mesoderm, 


m.g. 


P-g- 


■^ ' 


J^lpf^-^      _P'*.s^ 


extends  out  on  either  side.  At  the  an- 
terior limit  of  the  primitive  streak  is 
located  Hensen's  knot;  here  the  three 
primary  germ  layers  are  in  intimate 
union;  from  this  point  grows  forward  the 
so-called  head  process  from  which  the 
future  body  arises.  The  primitive  streak 
in  higher  vertebrates  is  an  elongated  rep- 
resentative of  the  blastopore  of  the  am- 
phibia (Fig.  62),  which  in  its  turn  repre- 

*  Some  investigators,  notably  O.  Hertwig,  dissent  from  this  interpretation.  Hertwig 
considers  a  stage  like  that  of  d,  Fig.  57,  as  a  single-layered  blastula,  and  believes  that  here, 
as  in  other  vertebrates,  a  two-layered  gastrula  arises  by  invagination  or  ingression  of  cells. 


Fig.  65. — Dorsal  View  of  a  Human  Em- 
bryo. 1.54  mm.  long.  X30.  The  am- 
nion, am.,  is  nearly  all  removed.  The 
yolk-sac,  y.s.,  shows  blood  islands.  The 
elongated  embryo  shows  a  medullary 
groove,  m.g.,  the  neurenteric  canal,  n.c, 
and  the  primitive  streak.  The  abdom- 
inal stalk,  a. 5.,  connects  it  to  the  chorion, 
c,  with  its  branched  villi,  p.g..  Primi- 
tive groove.  From  a  wax  reconstruc- 
tion.— {After  Graf  Spee.) 


54 


PHYSIOLOGICAL  PREGNANCY. 


sents  a  modified  gastrula  mouth  of  the  still  earlier  forms  (Fig.  60).  The  blasto- 
pore of  amphibia  becomes  covered  by  an  unequal  growth  of  cells,  its  last  trace 
being  in  the  neurenteric  canal  which  connects  the  primitive  enteron  with  the 
caudal  end  of  the  neural  canal  (Fig.  63).  A  neurenteric  canal  with  the  same 
essential  relations  is  found  in  higher  vertebrates  at  the  cephalic  end  of  the  primi- 
tive streak.  Finally  blastopore,  primitive  streak,  and  neurenteric  canal  dis- 
appear, leaving  no  trace,  but  they  are  of  profound  interest,  since  they  form  a 


^fe^'    m. 


Fig.  66. — Sagittal  Section  of  Fig.  65.  Showing  in  addi- 
tion the  allantoic  process,  the  complete  amnion,  am.,  with 
a  slight  extension  toward  the  chorion,  c,  and  the  thickening 
of  the  mesoderm,  m.,  where  the  heart  will  develop,  m.p., 
Medullary  plate;  h.f.,  heart  fold;  c.v.,  chorionic  viUi;  a.s., 
allantois  stalk;  p.s.,  primitive  streak;  a.c,  allantoic  canal; 
y.s.,  yolk  sac;  en.,  entoderm;  v.,  vessels;  p.s.,  primitive 
streak. 


Fig.  67. — Cross-section  of 
Fig.  65.  Shows  the  ecto- 
derm forming  the  medul- 
lary folds  and  groove  and 
at  the  right  thinning  to 
form  the  amnion,  am., 
Amnion;  ek.,  ectoderm; 
ct.,  amniotic  mesoderm; 
g.,  meeting  point  of  soma- 
topleure  and  splanchno- 
pleure;  df.,  mesoderm  of 
yolk  sac;  b,  b,  b,  blood- 
vessels; en.,  entoderm;  n, 
blastopore;  d,  cavity  of 
yolk-sac,  —  (After  Graf 
Spee.) 


common  landmark  in  early  development  throughout 

the  vertebrate   series,  marking  the  point  from  which 

the  mesoderm  takes  its  origin.     The  neurenteric  canal 

is  seen  in  a  very  early  human  ovum  described  by  Graf 

Spee  (Fig.  65).     According  to  Mall,  its  last  remnant  is 

distinct  until  adult  structures  are  sufficiently  developed 

to  determine  its  relative  location,  it  being  at  the  level  of  the  first  rib.     This  one 

fact  shows  that  the  structures  derived  from  the  head  and  neck  are  the  earliest  to 

be  laid  down,  the  whole  of  the  trunk  and  limbs  being  of  later  formation. 

Formation  of  Primitive  Organs. — The  early  embryology  of  organs  has  also 
been  much  more  completely  studied  in  the  lower  animals,  though  the  differences 
that  have  been  observed  between  the  latter  and  man  do  not  appear  to  be  so 
radical  in  the  organs  as  in  the  original  layers.     If  the  rabbit  be  taken  as  the 


FORMATION   OF  PRIMITIVE  ORGANS. 


55 


type,  after  the  three  layers — ectoderm,  entoderm,  and  mesoderm — are  differen- 
tiated, the  ectoderm  at  some  Httle  distance  in  front  of  the  primitive  streak 
by  a  process  of  unequal  growth  becomes  folded  in,  and  in  a  similar  way  at  the 
caudal  end,  while  at  either  side  folds  are  also  formed,  until  by  this  means  the 
embryo  is  outlined  and  somewhat 
raised  above  the  general  level  of 
the  embryonic  shield.  At  the 
same  time  other  folds  affecting  the 
ectoderm  appear  at  either  side  of 
the  axis  and  gradually  extend 
caudally.  These  are  the  medul- 
lary folds,  between  which  lies  the 
medullary  groove.  The  folds  arise 
above  the  general  level  (Figs.  65, 
66,  and  67),  and  as  they  grow  up- 
ward, fold  over  toward  each  other 
until  they  unite  to  form  a  tube. 
This  is  the  neural  tube,  and  is  at 
first  in  connection  with  the  ecto- 
derm of  the  general  surface  of  the 
body,  which  is  now  called  the  epi- 
dermis.    The  first  closure  of  the 

tube  is  in  the  neck  region,  the  closure  extending  both  forward  and  back  As 
the  closure  proceeds  the  tube  is  separated  from  the  epidermis  (Figs.  68  and 
69).     At  either  side,  just  at  the  junction  of  the  part  of  the  ectoderm  which 


Fig.  68. — Transverse  Section  of  a  Mole  Em- 
bryo. (Heape's  Stage  H.)  am.,  Amnion;  Md., 
medullary  grove;  My.,  primitive  segment;  Ccb., 
coelom;  En.,  entoderm;  nch.,  notochord;  ao., 
aorta;  vt.a.,  vitelline  artery;  Som.,  somatic  meso- 
derm; Spl.,  splanchnic  mesoderm. — {After  W. 
Heape.) 


Fig.  69. — Cross-section  through  the  Rump  of  a  Rabbit  Embryo  of  Eight  Days  and 
Three  Hours.  The  medullary  or  neural  tube,  Md.,  is  closed  and  completely  .separated 
from  the  epidermis,  which  is  continuous  with  the  epithelial  layer  of  the  amnion  and  chor- 
ion. At  this  level  amnion  and  chorion  have  not  separated  and  the  folds  forming  them 
have  not  yet  quite  united.  The  notochord  {Ch)  is  separated  from  the  entoderm  {Ent) . 
The  primitive  segments  {Seg)  are  hollow.  The  body-cavity,  Coe.,  is  continuous  with  the 
extraembryonic  cavity.  There  are  still  two  aortae,  Ao.;  Cho.,  chorion;  Am.,  amnion; 
Som.,  somatopleure ;  Spl.,  splanchnopleure, — {After  Minot.) 


is  to  form  skin  with  that  which  is  to  form  the  neural  tube,  there  is  a  thicken- 
ing of  ectoderm  which,  in  the  form  of  a  cord,  becomes  free  from  its  attachment 
to  the  former.     These  cords  come  to  lie  on  both  sides  of  the  neural  tube  and 


56 


PHYSIOLOGICAL  PREGNANCY. 


give  rise  to  the  nervous  ganglia  and  to  the  sensory  roots  of  the  nerves,  and 
also  finally  to  the  sympathetic  system.  Before  the  closure  of  the  tube  is  com- 
plete two  pockets  arise  from  it  on  the  two  sides  near  the  cephalic  end.     These 


h.c. 
nt.c. 


;^  t.c.r. 


Fig.  70. — Sagittal  Section  of  a  Rabbit 
WITH  8  TO  12  Myotomes.  Shows  the 
neural  tube  hollow  and  beveled  to  form 
the  fore-brain,  f.b.;  the  chorda,  c,  bent 
and  touching  the  hypophysis,  h.c;  the 
bUnd  end  of  the  entoderm,  en.,  coming 
in  contact  with  the  ectoderm  to  form  the 
oral  plate ;  the  continuation  of  the  ecto- 
derm to  form  the  amnion,  ant.;  the  heart, 
h.,  prominent  and  just  below  the  mouth- 
cavity,  m.c.  t.c.r.,  Trabeculse  cranii  of 
Rathke;  f.g.,  foregut. — {After  Keibel.) 


Fig.  71. — Section  of  a  Model  of  a  Three 
Weeks'  Human  Embryo,  showing  the 
Optic  Vesicles  as  Outpocketings  from 
THE  Brain. — (Stisanna  Phelps  Gage.) 
V .fug.  Jugular  vein;  inf,  inf undibultim ; 
Dien,  diencephalon ;  Mesen,  mesen- 
cephalon; O.V.,  optic  vesicle;  the  notch 
at  the  tip  is  the  beginning  of  the  optic 
cup. 


-~:^^<\-^!'0\   \^ 


are  the  first  indications  of  the  eyes.     As  the  tube  closes  the  pockets  extend 
farther  and  farther  outward,  becoming  partly  constricted  off  from  the  tube  (Fig. 

71).  The  outer  surface  of  the  pocket  be- 
comes pushed  inward  against  the  inner 
surface  until  a  double- walled  cup  (Fig.  72) 
is  formed,  which  ultimately  becomes  the 
many-layered  retina,  connected  with  the 
brain  by  the  stalk  which  elongates  and  in 
which  are  developed  the  fibers  of  the  optic 
nerve.  The  optic  cup  gives  rise  to  few  other 
parts  of  the  eye,  but  the  larger  portion  of 
them  is  produced  from  the  mesoderm, 
which  pushes  in  and  around  these  funda- 
mental parts  (Fig.  72).  At  the  same  time 
that  the  optic  cup  is  forming  the  ectoderm 
which  covers  it  is  producing  an  ingrowing 
pocket,  which  by  a  similar  process  is  con- 
stricted and  finally  wholly  separated  from 
the  ectoderm  to  form  the  lens  of  the  eye, 
which  fits  into  the  opening  of  the  optic  cup 
(Fig.  72).  The  ectoderm  also  gives  rise 
to  the  internal  ear,  which  is  completely  constricted  off,  and  to  the  external  ear 
and  the  nasal  epithelium,  which  form  deep  pockets  but  are  never  separated  from 


CO. 

e. 


Fig.  72. — Section  through  the  De- 
veloping Eye  of  a  Human  Embryo 
(10.2  MM.  Long).  Shows  the  open 
stalk  connected  with  the  mid-brain; 
the  double-walled  optic  cup ;  the  vesi- 
cle of  the  lens  cut  off  from  the  ecto- 
derm, ec;  and  mesoderm  growing  in 
to  form  the  cornea,  c,  vitreous  humor 
(v.h.),  etc.  w.,  Mesoderm;  r.L,  retinal 
layer;  p. I.,  pigment  layer;  s.  and  c, 
sclera  and  chorioidea;  t.,  thalamen- 
cephalon;  co.,  conus  opticus ;  e.,  epen- 
dyma. — (After  Kallmann.) 


FORMATION  OF  PRIMITIVE   ORGANS. 


57 


the  exterior.  At  the  same  time  that  the  neural  tube  is  forming,  the  entoderm 
along  the  middle  line  and  just  below  the  neural  tube  is  by  evagination  and  sub- 
sequent constriction  forming  a  much  smaller  tube,  which  soon  becomes  soHd  and 
forms  the  notochord  (Figs. '68,  69),  the  first  trace  of  a  body-axis.  The  notochord 
does  not  extend  to  the  cephalic  tip  of  the  neural  tube,  but  stops  at  the  hypophysis 
(Fig.  70);  that  is,  near  the  level  of  the  sella  turcica  of  the  adult  skull.  The 
chorda  and  its  cephalic  end  forms  landmarks  throughout  the  vertebrate  series 
and  from  very  early  stages  of  development.  In 
mammals  it  becomes  insignificant,  as  it  is  enclosed 
in  the  vertebral  column.  The  entoderm  at  first 
lines  a  simple,  unconstricted  yolk-sac  (Figs.  64  and 
66),  but  as  the  embryo  grows  out  over  the  almost 
stationary  sac  the  upper  portion  of  the  latter  be- 
comes separated  by  a  constriction  on  all  sides, 
more  pronounced  anteriorly  and  laterally,  to  give 
origin  to  a  continuous  tube  blind  at  both  its  ceph- 


vagfus  Tierce 

external 
carotid, 

'internal 
carotiet 


recurrent 
laryn^ea. 
nerve 


riffht^ 
'Siwclaviarv 


inrumtiruzte 
artery 


yertebral 

arch  of 
aorta 


Jlepa, 


ascending 

aortcv 


\.iefe . 

sabclaruiny 
arteriosus 


pidmonari/ 
trunk 


aorta^ 


Mn 


Fig.  73. — Diagram  showing  the  Destination  of  the 
Arterial  Arches  in  Man  and  Mammals. — {Modified 
from,  Rathke.) 


Fig.  74. — Scheme  of  the  De- 
velopment OF  THE  Chief 
Veins  of  the  Body. — (Quain.) 


alio  (Fig.  70)  and  caudal  ends,  the  alimentary  canal.  The  union  with  the  yolk-sac 
from  which  it  was  constricted  becomes  relatively  smaller  until  there  is  a  mere  stalk, 
vitelline  stalk  (Figs.  65  and  75),  at  the  extremity  of  which  is  the  yolk  vesicle.  In 
mammals  the  yolk-sac  grows  for  a  time,  and  though  it  contains  but  a  trace  of  nu- 
tritive yolk,  it  possesses  a  rich  network  of  blood-vessels,  known  as  the  omphalo- 
mesenteric vessels.  The  sac  loses  all  functional  importance  and  soon  begins  to 
atrophy,  but  persists  as  a  very  small  vesicle  until  birth,  when  it  may  be  found 


58 


PHYSIOLOGICAL  PREGNANCY. 


o.pt.v. 


among  the  decidual  tissues.  Each  of  the  bHnd  tubes  of  the  entoderm  above  men- 
tioned comes  in  contact  with  an  ingrowing  pouch  of  ectoderm.  The  double  layer 
so  formed  of  ectoderm  and  entoderm  (Fig.  70)  breaks  down,  thus  forming  the 
openings  from  the  alimentary  canal  to  the  exterior,  the  mouth  (Fig.  75)  and  the 
anus.  By  a  process  of  formation  of  pouches,  modified  sometimes  into  soHd  out- 
growths or  tubes,  the  ento- 
"^^-  derm  of  the  alimentary  canal 

gives  rise  to  the  lungs,  Hver 
(Fig.  75),  pancreas,  and  the 
special  glands  of  the  enteron. 
The  mesodermic  sheet  or 
layer  arises  at  the  primitive 
streak  and  first  pushes  for- 
ward at  either  side  of  the 
middle  line  but  not  crossing 
it.  The  portion  lying  next 
the  notochord  becomes  seg- 
mented. Each  of  these  seg- 
ments at  some  stage  is  hol- 
low and  is  called  a  somite 
(Fig.  69).  That  portion  of 
the  somite  which  lies  next 
to  the  ectoderm  and  is 
known  as  the  dermatome  or 
cutis  plate  fuses  with  it  to 
form  a  portion  of  the  skin. 
The  remaining  part  under- 
goes very  extensive  growth 
and  modification  to  form  the 
muscles  of  the  body  and 
limbs, and  an  important  part 
of  the  mesenchyma  from 
which  the  supporting  and 
bony  framework  of  the  body 
is  developed;  that  portion  of 
the  mesodermic  somite  from 
which  the  former  arises  is 
known  as  the  myotome  or 
muscle  plate;  that  from 
which  the  latter  structures 
arise  the  scelerotome.  That 
portion  of  the  mesoderm 
which  does  not  take  part  in 
the  formation  of  somites, 
and  which  lies  at  the  sides 
of  the  latter,  becomes  early 
divided  into  two  layers,  one  of  which  unites  with  the  ectoderm  to  form  the 
somatopleuric  or  parietal  layer, — which  gives  rise  to  the  body-wall,  the  amnion 
and  chorion, — while  the  other,  uniting  with  the  entoderm,  forms  the  splanchno- 
pleuric  or  visceral  layer,  which  gives  rise  to  the  alimentary  canal  and  its  deriva- 
tives (Figs.  67  and  68).  It  is  the  mesodermic  portion  of  the  latter  which  gives 
rise  to  the  muscles  and  connective  tissue  of  the  alimentary  canal. 


Fig.  75. — Human  Embryo  at  Third  Week.  The  left 
body-wall  or  side  has  been  removed,  so  that  the  neural 
canal  and  gut  are  exposed.  The  left  wall  of  the  anterior 
end  of  the  gut  and  the  still  very  broad  vitelline  duct 
have  also  been  removed,  th.,  Thalamencephalon;  o.v., 
optic  vesicle;  c.h.,  cerebral  hemisphere;  b.c,  branchial 
clefts;  t a.,  truncus  arteriosus;  Z.,  lung;  a.,  auricle;  li., 
liver;  o.m.v.,  omphalo-mesenteric  vein;  v.d.,  vitelline 
duct;  ^,tail;  u.a.,  umbilical  artery;  mi.,  midbrain  or 
mesencephalon;  m.,  medulla;  d.a.,  descending  aorta; 
c,  chorda;  e.,  esophagus;  5.,  stomach;  V.,  intestine. — 
{After  His's  model.) 


Fig.  76. 

12th  day 

(nat.  size). 


Fig.  77. 
2ist  day 
(nat.  size). 


Fig.  78. 

30th  day 

(nat.  size). 


Fig.  79. 

34th  day 

(nat.  size). 


Fig.  80. 

6i  week 

(nat.  size). 


Fig.  81. — End  of  2d  month  (62d 
day)  (nat.  size). 


j^^f^^-^j^ 


Fig.  82. — End  of  3d  month 
(nat.  size). 


Fig.  83. — End  of  4th  month  (nat.  size). 


Figs.  76  to  83. — Natural  size  and  Development  of  the  Human  Embryo  in  the  First 

Four  Months  of  Pregnancy. 

(Figs.  76  to  Si  are  from  His,  and  Figs.  82  and  83  are  from  Bumm's  fresh  fetuses.) 


59 


60 


PHYSIOLOGICAL  PREGNANCY. 


The  space  formed  by  the  separation  of  these  two  layers  of  mesoderm  is  the 
body-cavity  or  ccelom.  At  first,  in  man,  it  seems  to  be  separate  from  the  extra- 
embryonic coelom  (Fig.  67)^  but  soon  becomes  continuous  with  it,  as  in  the  rabbit 
(Fig.  69).  Later  this  connection  is  lost  by  the  growth  of  the  body-walls  to  unite 
around  the  umbiHcal  cord.  The  body-cavity  proper  is  divided  by  the  gradual 
growth  of  the  diaphragm  into  abdominal  and  thoracic  cavities.  The  thoracic 
cavity  is  further  divided  into  the  pericardial  and  the  two  pleural  cavities.  All 
the  supporting  and  connective  tissues,  as  bone,  cartilage,  and  the  muscles  and 


Figs.  84,  85,  86,  87. — Fetal  Skulls  of  the  First  Third  of  Pregnancy  (Two-thirds 
Natural  Size). — {Author's  collection.) 

blood-vessels,  take  their  origin  from  the  mesoderm;  but  while  the  problems 
involved  in  a  full  consideration  of  the  mesoderm  and  ccelom  are  fundamental 
in  character,  they  are  very  complex  and,  moreover,  have  not  been  satisfactorily 
worked  out  in  their  finer  details.  (For  the  heart  and  vascular  system,  see  sec- 
tions on  Nutrition  and  Circulation.) 

The  urogenital  system  is  derived  from  a  cord  of  tissue  lying  between  the 
somites  and  the  coelom  (Fig.  69).  This  early  forms  the  Wolffian  or  pronephric 
duct,  which  gives  rise  to  tubules  forming  the  primitive  excretory  apparatus, 
the  mesonephros  or  Wolffian  body      In  lower  vertebrate  forms  a  fetal  kidney, 


Figs.   88,  89,  90. — Fetal  Skulls  of  the  Middle  Third  of   Pregnancy  (Two-thirds 
Natural  Size). — {Author's  collection.)' 


called  the  pronephros,  precedes  the  mesonephros.  It  exists  in  a  very  rudi- 
mentary condition  in  the  human  embryo.  With  the  exception  of  its  duct  it 
entirely  disappears  to  make  way  for  the  mesonephros.  This  structure  projects 
far  into  the  coelom  and  its  mesothelial  covering  cells  which  give  rise  to  the 
Mullerian  duct,  and  to  the  ova  or  zoospores,  the  essential  parts  of  the  ovary 
or  testis.  The  mesonephros  disappears,  gradually  giving  place  to  the  definite 
kidney  or  metanephros,  but  its  duct  at  the  caudal  end  gives  rise  to  the  duct 
and  tubules  of  the  true  kidney.     In  the  male  it  produces  the  vas  deferens. 


GERM-LAYER.  61 

In  the  female  the  Miillerian  ducts  are  transformed  into  the  Fallopian  tubes 
and  caudally,  by  their  union,  into  the  uterus  and  vagina.  The  limbs  arise  as 
mere  pads  of  indifferent  mesodermic  tissue  covered  by  ectoderm.  Into  them 
gradually  extend  outgrowths  of  the  myotomes  producing  muscles  and  carrying 
with  them  the  vessels  and  nerves  which  have  already  joined  them.  A  part 
of  the  mesoderm  is  condensed  in  rod-like  forms.  The  connective-tissue  cells 
are  transformed  into  cartilage  in  those  portions  of  the  rods  which  are  to  form 
the  bones.  Where  the  joints  are  to  be,  the  condensed  connective  tissue  persists, 
forming  amphi-arthrodial  joints.  The  true  synovial  joints  are  developed  later 
by  a  solution  of  the  connective  tissue  between  the  ends  of  the  cartilages.  The 
hands  are  formed  gradually  from  mere  pads  and  the  fingers  are  at  first  webbed. 
In  the  main  outlines  human  differentiation  of  organs  is  like  that  of  the  rabbit, 
as  shown  by  the  fact  that  the  selected  illustrations  are  mostly  human;  but  in 
one  important  particular  the  distinctively  human  development  differs  from 
that  of  the  rabbit,  the  body  being  outlined  from  outlying  portions  at  a  later 


Figs.  91  and  92. — Fetal  Skulls  of  the  Ninth  and  Tenth  Months  of  Gestation 
(Two-thirds  Natural  Size). — {Author's  collection.) 

stage  relatively  than  in  that  animal.     In  this  respect  it  more  nearly  resembles 
the  mouse  (see  Membranes,  page  61). 

Tissues  or  Organs  Derived  from  Each  Germ-layer. — Ectoderm:  (i)  Ectodermic 
layer  of  chorion  and  amnion.  (2)  Epidermis  with  appendages  (hair  and  nails); 
the  epithelium  of  (a)  all  skin  glands  including  the  mammary ;  (6)  the  stomodeal 
portion  of  the  mouth,  including  the  salivary  glands  and  the  enamel  of  the  teeth; 
{c)  the  nasal  passages,  upper  part  of  the  pharynx,  and  the  hypophysis;  {d)  the 
proctodeal  portion  of  the  alimentary  canal;  {e)  the  crystalline  lens  and  the  ex- 
ternal ear.  (3)  The  whole  of  the  nervous  system,  brain,  spinal  cord,  nerves, 
ganglia,  and  epithelial  portions  of  the  organs  of  sense  (retina,  internal  ear,  olfac- 
tory, taste  and  tactile  organs).  Mesoderm:  (i)  The  urinary  and  genital  organs, 
except  the  lining  of  the  bladder  and  urethra.  (2)  The  skeleton  and  all  support- 
ing connective  tissue.  (3)  All  muscles,  both  striated  and  unstriated.  (4)  (a) 
The  epithelium  of  the  vascular  and  lymphatic  systems  and  of  serous  cavities 
derived  from  the  coelom  or  arising  in  joints;  (6)  blood  and  lymph.  Entoderm: 
The  epithelium  of  the  alimentary  canal  (exclusive  of  the  stomodeum  and  proc- 
todeum) with  that  of  its  derivatives.  Eustachian  tube,  thymus,  thyroid,  lungs, 
liver,  pancreas,  bladder,  urethra,  urogenital  sinus,  and  all  the  small  glands  and 


62 


PHYSIOLOGICAL  PREGNANCY. 


ORIGIN   OF  MEMBRANES.  63 

tubules,  together  with  the  rudimentary  allantois  and  the  yolk-sac  belonging  to 
the  membranes. 

Origin  of  Membranes. — The  membranes  are  the  extra-embryonic  portions 
of  the  ovum  which  serve  to  aid  in  its  protection  and  nutrition.  Because  of  the 
ease  and  frequency  of  the  study,,  the  most  familiar  type  of  membrane  formation 
has  come  to  be  that  of  birds.  In  these  animals  the  folds  of  united  mesoderm 
and  ectoderm  or  the  somatopleure  (see  above),  which  have  been  tucked  in  all 
around  to  outline  the  embryo,  rise  up  outside  the  embryonic  region  until,  like 
the  medullary  folds,  they  unite  over  the  back  of  the  embryo  to  form  a  closed 
sac.  Synchronous  with  the  upward  growth  a  still  more  peripheral  portion 
of  the  splanchnopleure  continues  around  the  ventral  portion  until  a  union  takes 
place.  This  results  in  the  formation  of  a  continuous  sac  enclosing  both  embryo 
and  yolk-sac.  The  portion  of  the  membranous  sac  dorsal  to  the  embryo  is  now 
composed  of  two  layers  connected  in  the  middle  line.  The  line  of  junction 
breaks  down,  and  there  results  an  inner  closed  sac,  the  amnion,  covering  in  the 
dorsal  part  of  the  embryo  and  formed  by  an  extension  of  its  body-wall;  and 
an  outer  closed  sac,  the  chorion,  which  encloses  not  only  the  amnion  with  the 
embryo,  but  the  yolk  which  depends  from  the  ventral  side  of  the  latter.  It 
also  includes  the  white  of  the  egg  and  lies  next  the  shell  From  the  caudal  end 
of  the  entoderm  grows  out  a  sac,  the  allantois,  covered  with  the  splanchnopleuric 
layer  of  mesoderm  and  carrying  with  it  blood-vessels  from  the  heart.  The 
allantois  expands  until  it  comes  in  contact  with  the  chorion,  where  it  brings 
its  blood-vessels  close  to  the  exterior,  thus  serving  as  an  organ  of  respiration. 
In  some  mammals,  as  the  rabbit,  horse,  pig,  and  cow,  a  modification  of  the 
above  method  of  membrane  formation  occurs  which  is  in  the  nature  of  an  abbre- 
viation of  the  process.  As  stated  above,  in  such  forms  the  ovum  consists  at 
the  end  of  segmentation  of  an  outer  Rauber's  layer,  with  a  nodule  of  cells  at 
one  pole  (Fig.  57).     The  cells  at  the  pole  multiply  and  spread  out  in  the  form 


Fig.   93. — Five  Schematic  Figures  Illustrating  the  Fetal  Membranes;  all  these, 

WITH  THE  Exception  of  the  Last  Embryo,  are    Represented  in  Longitudinal 

Section. —  {After  Koelliker.) 

1,  Blastodermic  vesicle  with  zona  pellucida,  segmentation  cavity,  germinal  area,  and 
site  of  the  embryo.  2,  Blastodermic  vesicle  wj^h  developing  yolk-sac  and  amnion.  3, 
Blastodermic  vesicle  with  closing  amnion  and  protrusion  (or  budding)  of  the  allantois. 
4,  Blastodermic  vesicle  with  chorionic  villi,  larger  allantois,  and  embryo  with  oral  and  anal 
orifices.  5,  Blastodermic  vesicle  showing  vascular  allantois  in  contact  with  the  chorion 
and  penetrating  the  villi  of  the  same;  an  umbilical  cord  is  indicated;  the  yolk-sac  is  atrophic 
and  the  amniotic  cavity  is  increasing  in  size.  The  ectoblast  is  represented  in  yellow,  the 
visceral  mesoblast  and  the  vascular  layer  of  the  allantois  and  yolk-sac  are  red,  the  ento- 
blast  green.  The  zona  pellucida  in  Figs,  i  to  3  is  represented  in  black,  as  are  also:  Fig.  i, 
the  entire  middle  germinal  layer;  Figs.  2,  3,  and  4,  the  parietal  mesoblast  of  the  amnion; 
Figs.  2  to  5,  the  mesoblast  in  the  neighborhood  of  the  embryo,  with  the  exception  of  the 
splanchnopleure  and  heart. 

a.  Place  at  the  origin  of  the  embryo  showing  thickening  of  the  wall  of  the  germinal 
vesicle;  ac,  amniotic  cavity;  al,  allantois;  am,  amnion;  ar,  commissure  of  the  amnion;  as, 
amniotic  fold  of  the  umbilical  cord;  vs,  vascular  layer  of  the  allantois;  vv,  vascularized 
chorionic  villi;  d,  zona  pellucida;  dd,  site  of  the  gut  lined  with  entoblast;  this  site  originates 
from  a  portion  of  the  inner  layer  of  the  blastodermic  vesicle  (later  the  epithelium  of  the 
yolk-sac);  vd,  vitelline  duct;  e,  embryo;  h,  region  of  the  heart;  gc,  segmentation  cavity 
which  later  becomes  Ys,  the  cavity  of  yolk-sac;  cs,  head-fold  of  the  amnion;  nt,  thickening 
of  the  middle  layer  of  the  blastodermic  vesicle  which  is  a  part  of  the  site  of  the  embryo 
m' ,  at  first  extending  no  further  than  the  germinal  area;  ex,  original  space  between  amnion 
and  chorion  (exocoelom) ;  ch,  chorion,  as  yet  without  villi  (serous  covering) ;  cs',  tail-fold 
of  the  amnion;  st,  region  of  the  sinus  terminalis;  u,  urachus  (allantoic  stalk);  vl,  anterior 
body-wall  in  the  region  of  the  heart. 

In  figures  2  and  3  the  amniotic  cavity  has,  for  the  sake  of  clearness,  been  drawn  too 
large.  The  cavity  of  the  heart  has  everywhere  been  represented  too  small  and  many 
details,  more  particularly  the  body  of  the  embryo,  have,  with  the  exception  of  figure  5, 
simply  been  shown  schematically. 


64 


PHYSIOLOGICAL   PREGNANCY. 


of  a  plate  which  gives  rise  to  the  three  layers,  the  ectoderm  becoming  continuous 
with  Rauber's  layer.  The  entoderm  grows  around  inside  the  ectodermal  layer 
and  forms  the  hollow  yolk-sac  The  splanchnopleure  never  completely  invests 
the  yolk,  as  it  does  in  the  chick;  the  somatopleure  forms  the  amnion  outside 
the  embryo  and  a  chorion  which  separates  from  the  amnion  (Fig.  69);  the 
principal  modification  consisting  in  the  fact  that  as  the  mesoderm  does  not 
extend  to  the  ventral  limit,  the  chorion,  composed  of  ectoderm  and  mesoderm, 


CAorion  /70/if/osf/m 

Jfeadof 
£7nAryo 


f/z/iht/rmlVesLclc  (Af/vp/iruvijrJ 


Amnionic 
farify" 


J/i/esiinal' 
^^^^^^  Caruil'. 

C/u>rioni^eye 

Fig.  94. — Schematic  Representation  of  Early  Embryonic  Structures. 


is  not  completed  on  the  ventral  side.  This  interval  is  completed  by  the  simple 
layer  of  ectoderm  forming  Rauber's  layer.  The  modification  is  still  further 
emphasized  by  the  atrophy  and  disappearance  of  the  cells  of  this  layer.  The 
facts  just  stated  have  given  rise  to  many  ill-founded  theories  with  regard  to 
human  development;  thus,  Rauber's  layer  was  supposed  to  have  no  relation 
to  the  true  ectoderm,  and  as  the  entoderm  seemed  to  come  to  the  surface,  it  was 
supposed  that  there  was  a  so-called  "inversion  of  the  germ-layers." 


Fig.  95. — Human  Ovum  Twelfth  to  Thirteenth  Day. — {Reichert.) 


Another  modification  of  the  membrane-formation  which  has  been  used  to 
explain  the  condition  in  man  is  well  illustrated  in  the  mouse  and  some  other 
rodents.  The  heap  of  cells  at  the  pole  first  differentiates  off  a  few  entodermal 
cells  which  multiply  and  form  a  layer.  A  cavity  then  appears  in  the  ectodermic 
portion  of  the  mass  of  cells  which  enlarges  so  greatly  as  to  form  a  sac  nearly 
covered  by  the  ectodermic  layer,  the  whole  extending  far  into  the  interior  of 


THE  MEMBRANES  AT  TERM.  65 

the  outer  or  Rauber's  layer  of  the  ovum.  The  embryo  is  formed  at  the  deepest 
portion  of  this  invagination.  The  amnion  is  produced  by  the  growing  together 
in  an  hour-glass-Uke  formation  of  the  invagination  over  the  back  of  the 
embryo;  the  remaining  portion  next  the  original  implantation  of  the  heap  of 
cells  becoming  the  chorion  and  finally  a  part  of  the  placenta.  Here,  too,  the 
remaining  portion  of  the  ectoderm  in  Rauber's  layer  does  not  apparently  become 
a  part  of  the  chorion.  Contrary  to  the  condition  in  the  chick,  rabbit,  and  many 
other  mammals,  the  allantois  of  the  mouse  does  not  form  a  large  pouch  of  ento- 
derm, but  is  a  small  tubular  invagination  of  the  yolk-sac.  It  is,  however,  covered 
by  mesoderm,  which  continues  as  a  sheet  over  the  chorion  and  carries  the  blood- 
vessels of  the  embryo  to  the  placenta,  where  the  blood  is  aerated. 

In  Peters 's  embryo,  the  youngest  human  specimen  studied,  it  is  seen  that 
the  conditions  are  not  as  in  the  chick,  with  early  formation  of  embryo  and  sub- 
sequent differentiation  of  membranes;  nor  as  in  the  rabbit,  nor  even  quite  as  in 
the  mouse.  The  membranes  in  Peters's  embryo  have  been  developed  preco- 
ciously (Fig.  51).  The  chorion  is  a  completely  closed  sac  with  amesodermic  lining, 
such  as  occurs  quite  late  in  the  chick.  There  is  no  sign  of  the  disintegration 
of  the  outer  ectodermic  layer,  as  in  the  Rauber's  layer  of  the  rabbit,  but  later 
stages  (according  to  Mall)  indicate  that  it  becomes  transformed  into  the  syncy- 
tial layer  of  the  chorion  {q.  v.).  The  amnion  is  also  a  closed  sac  with  the  un- 
differentiated embryo,  a  simple  thickened  plate  of  cells,  lying  in  its  deepest 
portion,  thus  having  a  strong  resemblance  to  the  early  condition  in  the  mouse. 
The  yolk-sac  is  also  closed  and  is  larger  than  the  amnion,  but  is  not  constricted 
with  any  indication  of  an  alimentary  tract,  as  would  be  the  case  in  the  chick 
at  a  similar  stage  of  development  with  reference  to  the  mesoderm.  The  latter 
has,  indeed,  attained  a  remarkable  development.  It  has  entirely  invested  the 
yolk-sac  forming  the  splanchnopleure,  while  the  somatopleure  is  represented 
by  the  amnion  and  the  chorion  completely  invested  by  the  mesoderm  before 
there  is  an  indication  of  the  formation  of  somites.  Whether  the  amniotic  sac 
becomes  hollowed  out  of  a  solid  mass  of  cells,  as  seems  to  be  the  case  in  the 
mouse,  or  whether  there  is  only  a  division  of  the  amnion  from  the  chorion,  such 
as  occurs  in  the  rabbit  (as  surmised  by  His  and  Nagel),  although  taking  place 
relatively  earlier,  cannot  be  determined  without  further  investigation.  In  Graf 
Spec's  embryo  (Figs.  65  and  66),  and  in  an  ape  examined  by  Selenka,  an  appear- 
ance is  found  which  points  to  the  latter  conclusion ;  since  the  amnion  in  these  speci- 
mens has  a  diverticulum  pointing  toward  the  chorion,  as  though  just  constricted 
off  therefrom.  The  important  point  in  this  connection  is  that  the  amniotic  sac 
never  separates  completely  from  the  chorion  as  with  the  rabbit,  but  remains 
connected  with  it  by  a  broad  band  of  mesoderm.  In  the  next  later  stages  of 
human  embryos  it  is  found  that  a  small  diverticulum  of  the  yolk-sac  extends 
into  this  mass  of  mesoderm,  which  has  become  relatively  smaller,  forming  the 
stalk  which  with  further  development  becomes  the  umbilical  cord.  Although 
a  true  allantois — in  the  sense  that  it  occurs  in  the  chick  and  many  mammals — 
is  not  present,  the  mesodermic  layer  of  that  organ  may  be  said  to  exist;  since  the 
blood-vessels,  when  they  arise,  pass  by  way  of  this  allantoic  rudiment  through  the 
abdominal  stalk  to  the  chorion.  To  sum  up,  but  that  this  earliest  human  ovum, 
before  an  embryo  has  even  been  outlined,  has  membranes  of  a  stage  of  develop- 
ment corresponding  to  a  much  later  stage  in  the  chick,  a  closed  chorion,  a  closed 
amnion,  a  closed  yolk-sac.  The  essential  difference  is  that  there  is  no  free  allan- 
tois containing  an  extensive  entodermic  cavity,  and  that  the  mesoderm  con 
nects  the  embryo  with  the  chorion  from  the  earliest  stages  and  not  secondarily. 

The  Membranes  at  Term. — At  term  the  fetus  is  surrounded  by  three  mem- 
5 


66 


PHYSIOLOGICAL  PREGNANCY. 


branes,  two  of  which  are  of  fetal  and  one  of  maternal  origin.  Their  order,  from 
within  outward,  is:  amnion,  chorion  of  fetal  origin,  and  decidua  refiexa  and 
vera  of  maternal  origin. 

The  Amnion. — As  seen  above,  the  amnion  is  the  innermost  of  the  fetal  mem- 
branes. At  first  it  encloses  only  the  dorsal  part  of  the  embryo,  but  with  growth 
and  closure  of  the  body- wall  around  the  umbilicus,  it  completely  invests  the 
embryo  except  that  the  cord  passes  through  it.  It  is  continuous  with  the  fetal 
epidermis  at  the  umbilicus  (Figs.  65,  66,  67,  93,  and  94).  It  consists  of  two 
layers,  one  of  flattened  cells  derived  from  the  ectoderm  and  continuous  with 
the  epidermis,  the  other  of  connective-tissue  cells  and  fibers,  mesoblastic  in 
origin.  The  enclosed  space  constitutes  the  true  amniotic  cavity  or  sac,  and 
its  chief  function  is  the  secretion  of  liquor  amnii.  At  first  the  amnion,  as  com- 
pared with  the  embryo,  is  quite  large.  Then  the  embryo  grows  more  rapidly 
and  the  amnion  closely  invests  it ;  and  finally  at  the  second  month  a  more  rapid 

growth  of  the  amnion  takes 
place,  which  ultimately  re- 
sults in  a  close  relationship 
between  it  and  the  chorion. 
As  long  as  a  cavity  exists  be- 
tween amnion  and  chorion  it 
is  sometimes  called  the  false 
amniotic  cavity  and  is  filled 
with  a  liquid  somewhat  sim- 
ilar to  the  amniotic  fluid.  At 
birth  the  bag  of  waters  con- 
sists of  the  amnion  and  part 
of  the  chorion.  Sometimes 
this  is  not  ruptured  until  after 
the  head  is  born. 

Liquor  Amnii. — The  am- 
niotic fluid  contained  in  the 
amniotic  sac  is  somewhat 
variable  in  quantity,  the  aver- 
age being  about  a  liter,  or 
quart.  Of  this,  nearly  one- 
half  is  formed  during  the  last 
three  lunar  months.  At  times 
this  fluid  is  very  scanty,  so  that  it  interferes  with  the  growth  of  the  fetus,  and 
causes  its  premature  expulsion.  There  is  on  record  a  case  in  which,  in  the 
absence  of  a  normal  supply  of  liquid,  ulcers  were  formed  on  the  knees  and 
ankles  of  a  fetus,  due  possibly  to  friction.  Many  other  deformities  have  been 
found  to  be  correlated  with  the  same  condition.  When  its  amount  is  exces- 
sive, the  condition  is  called  hydramnios,  in  which  many  quarts  of  fluid  may 
be  present.  The  amniotic  fluid  is  alkaline  in  reaction.  Its  greatest  bulk 
— nearly  99  per  cent. — consists  of  water,  in  which  are  found  albumin;  creatin; 
epithelial  cells  from  the  fetal  skin,  bladder,  and  kidneys;  sebaceous  material; 
urea  and  several  inorganic  salts  (phosphates,  chlorides);  as  well  as  many  other 
constituents.  Its  specific  gravity  varies  between  1.0005  and  1.0082.  It  is 
generally  opaque,  white  in  color,  although  this  may  change  from  the  presence  of 
unusual  ingredients,  meconium  giving  it  a  dark  brown  tinge,  while  a  macerated 
fetus  colors  it  red.  It  has  a  heavy  and  characteristic  odor.  Keim  has  found 
that  the  freezing-point  of  this  fluid  is  higher  at  term  than  that  of  the  maternal 


p.m. 


y.s. 


Fig.  96. — Ruptured  Human  Ovum  Fifteenth  to 
Eighteenth  Day.  Amnion  has  been  opened,  a.s., 
AUantois  stalk;  p.m.,  parietal  mesoblast;  y.s.,  yolk- 
sac;   a.,  amnion;  h.,  heart. — {Coste.) 


THE  LIQUOR  AM  NIL 


67 


or  fetal  blood-serum.  This  indicates  an  intrinsic  tendency  to  absorption.  Its 
origin  is  a  moot  question.  The  theory  that  it  consists  chiefly  of  fetal  urine  is 
disproved  by  chemical  analysis,  only  a  small  part  arising  from  this  source.  The 
fetal  tissues  contribute  a  small  portion  by  exudation.  The  greater  part  is  of 
maternal  origin  and  the  result  of  transudation  through  the  placenta.  The 
investigations  in  regard  to  the  two  sources  of  the  amniotic  fluid  have  been  as 
varied  as  they  are  interesting.  As  to  the  excretion  of  urine  by  the  fetus,  there 
seems  to  be  undeniable  evidence,  more  than  three  pints  of  this  excretion  having 
been  found  in  the  fetal  bladder.  After  the  communication  between  the  bladder 
and  the  exterior  of  the  body  is  completed  through  the  agency  of  the  urethra, 
there  is  from  time  to  time  a  passage  of  the  renal  secretion  from  the  fetus  into 
the  amniotic  fluid.  At  just  what  stage  of  fetal  development  this  occurs  has 
not  yet  been  decided.  This  prenatal  urine  is  very  poor  in  coloring-matters, 
as  may  be  seen  from  the  specimens  collected  soon  after  birth.     Another  theory 


Fig.  97. — Isolated  Terminal  Branch  of      Fig. 
Villus     from    the     Chorion     of     an 
Embryo  of  Twelve  Weeks. — (Minot.) 


:  .<y 


-Chorionic  Villi  at  Five  Months 
— {Minot.) 


supposes  that  the  fetal  skin  is  the  source  of  this  fluid,  and  there  has,  indeed, 
been  noted  in  several  cases  a  connection  between  affections  of  the  fetal  skin 
— in  one  instance  extensive  nevi — and  hydramnios.  The  view  that  much  of 
the  liquor  amnii  has  a  maternal  source  is  substantiated  by  the  results  of  numerous 
experiments.  Tuntz,  after  the  injection  of  sulphindigotate  into  the  veins  of 
pregnant  rabbits,  recognized  the  reagent  in  the  liquor  amnii  by  its  blue  coloring- 
matter,  while  there  was  no  trace  of  it  in  the  fetal  kidneys.  Experiments  with 
other  substances — e.  g.,  iodin,  salicylic  acid,  and  potassium  ferrocyanid — have 
been  made.  Chloroform  administered  to  the  mother  in  labor  has  been  demon- 
strated later  in  the  umbilical  circulation,  so  that  it  probably  exerts  an  an- 
esthetic influence  on  the  fetus.  However,  the  endeavor  to  introduce  such 
substances  as  fat,  vermilion,  and  india  ink  into  the  fetal  circulation  by  admin- 
istering them  to  the  mother  has  had  doubtful  success,  positive  results  being 
undoubtedly  dependent  on  injury  to  the  blood-vessels. 


68 


PHYSIOLOGICAL  PREGNANCY. 


There  has  been  much  discussion  as  to  the  passage  of  formed  elements,  such 
as  pathogenic  bacteria,  from  the  mother  to  the  fetus;  and  various  opinions 
are  held  on  the  subject.  Certain  substances  taken  by  the  mother  are  found 
later  in  the  liquor  amnii,  even  when  the  fetus  is  dead — showing  that  the  latter 
took  no  part  in  the  process.  Also  cases  in  which  the  product  of  conception  is 
early  destroyed  exhibit  an  amount  of  amniotic  fluid  corresponding  to  the  age 
of  the  ovum,  and  not  to  the  development  of  the  embryo. 

Functions. — The  functions  of  the  liquor  amnii  are  varied,  being  chiefly, 
however,  protection  for  mother  and  child.  It  saves  the  uterus  from  the  in- 
jurious effects  of  fetal  movements.  It  distends  that  organ,  and  thus  allows 
a  certain  freedom  of  movement  to  the  fetus,  and  by  the  prevention  of  adhesions 
between  the  amnion  and  child  it  lessens  the  chance  of  development  of  mon- 
strosities as  well  as  intrauterine  amputations  and  other  abnormalities,  and 
prevents  any  harmful  pressure  by  the  uterine  walls.  The  amniotic  fluid  has 
a  specific  gravity  near  enough  to  that  of  the  fetus  to  lessen  greatly  the  muscular 
efforts  in  its  movements.  It  protects  the  fetus  from  external  violence  and 
maintains  for  it  an  equable  temperature.  It  receives  and  dilutes  the  fetal 
secretions  and,  according  to  some  authorities,  serves  as  a  source  of  nourishment 

to  the  fetus.  This  last  sug- 
gestion has  little  foundation, 
although  the  presence  of 
lanugo  and  epithelial  cells  in 
the  meconium  shows  that  the 
amniotic  fluid  has  been  swal- 
lowed. It  is  quite  probable, 
however,  that  it-  supplies  to 
the  fetal  tissues  a  large  pro- 
portion of  the  water  which 
they  possess  before  birth,  in 
order,  according  to  Preyer, 
that  they  may  be  able  to  ab- 
sorb from  the  blood  of  the 
umbilical  vein  the  albumin 
and  salts  which  it  contains.  Finally,  the  hydraulic  action  of  the  amniotic  fluid 
is  most  valuable  in  labor.  It  forms  a  veritable  water- wedge,  and  serves  by  its 
downward  pressure  to  dilate  the  circular  muscle  bands  of  the  os  uteri ;  and  after 
being  released  from  the  amniotic  sac  it  acts  as  a  lubricant  to  the  birth  canal. 

The  Allantois. — The  allantois  in  many  mammals  is  a  diverticulum  of  the 
caudal  part  of  the  alimentary  canal,  which  carries  with  it  the  splanchnic  layer 
of  the  mesoderm  until  contact  is  made  with  the  chorion,  thus  forming  a 
large  sac  containing  fluid.  But  in  man  the  entodermic  diverticulum  is  a  mere 
rudiment  (Fig.  66)  which  can  be  traced  along  the  umbilical  cord  for  some  distance 
but  does  not  form  a  free  sac.  A  mesodermic  layer,  however,  perfectly  analogous 
to  that  of  other  mammals,  does  connect  the  caudal  end  of  the  embryo  with  the 
chorion  and  serves  to  carry  the  blood-vessels  from  the  embryo  to  the  chorionic 
villi.  This  mesodermic  layer,  as  seen  above,  is  precociously  formed.  As  in 
other  mammals,  the  proximal  portion  of  the  allantoic  rudiment  forms  the  urinary 
bladder  and  the  urachus  which  becomes  one  of  the  ligaments  of  the  latter. 

The  Chorion. — There  is  probably  no  organ  in  the  human  fetus  which  has 
been  the  subject  of  such  false  conceptions  as  the  chorion.  It  is  defined  by  Minot 
as  follows:  "The  whole  of  that  portion  of  the  extra-embryonic  somatopleure 
which  is  not  concerned  in  the  formation  of  the  amnion."     As  shown  above, 


Fig.  99. — Chorionic  Villi  at  Full  Term. — {Minot.) 


THE  CHORION. 


69 


the  young  human  ovum  already  has  a  chorion  with  a  mesodermic  lining  (Figs.  64 
and  51).  It  is  covered  by  villi,  solid  outgrowths  of  the  epithelial  layer,  which 
show  slight  cavities  at  their  bases  into  which  the  mesoderm  protrudes.  The 
villi  extend  into  the  uterine  mucous  membrane  in  such  a  way  as  to  indicate 
that  epithelium,  glands,  and  walls  of  blood-vessels  in  their  path  have  been  dis- 
integrated and  not  merely  pushed  aside;  that  is,  they  protrude  freely  into  the 
maternal  blood.  In  the  somewhat  later  stage  shown  in  Reichert's  ovum  (Fig. 
95)  the  villi  are  grouped  in  a  band,  leaving  the  two  flattened  poles  of  the  ovum 
bare.  Still  later  the  villi  become  hollow  with  two  distinct  layers  of  epithelium, 
and  soon  are  penetrated  by  blood-vessels  which  have  entered  the  mesoderm 
of  the  chorion.  The  simple  club-shaped  villi  of  the  early  ovum  soon  begin  to 
degenerate  on  the  side  next  to  the  decidua  refiexa  until  in  this  part  the  chorion 
is  smooth,  chorion  Icsve  (Figs.  53  and  104).  On  the  smaller  area  next  the  decidua 
serotina,  the  villi  become  greatly  enlarged  and  complexly  branched,  the  blood- 


FiG.    100. — Unruptured    Human    Ovum    of   about   Third    We£k,    showing   Chorion. 

X  2\. — {Author's  case.) 


vessels  of  the  embryo  following  the  ramification.  This  part  of  the  chorion  is 
called  the  chorion  frondosum,  and  becomes  the  fetal  portion  of  the  placenta 
(Figs.  53  and  100). 

The  outer  layer  of  the  epithelium  of  the  villi  undergoes  a  peculiar  modifica- 
tion. The  cells,  rapidly  developing,  do  not  entirely  separate,  but  form  a  syn- 
cytium *  with  numerous  nuclei.  As  seen  from  the  first,  this  has  a  destructive 
effect  on  the  uterine  mucosa  and  blood-vessels  (Fig.  64).  On  account  of  the 
theoretical  objections  to  the  idea  of  contact  of  fetal  epithelium  and  maternal 
blood  with  no  intervening  maternal  structures,  the  syncytium  has  been  considered 
by  many  as  an  altered  maternal  structure  covering  the  blood  sinuses.  All 
the  evidence  now  accumulating  seems  to  point  in  the  direction  above  stated, 

*  Syncytium:  (i)  A  single  cell  having  many  nuclei;  (2)  a  structure  composed  of  epi- 
thelial cells,  forming  the  outermost  fetal  layer  of  the  placenta  and  lying  between  the  decidua 
and  chorionic  villi  over  the  layer  of  Langhans. 


70  PHYSIOLOGICAL  PREGNANCY. 

that  it  is  a  fetal  structure;  and  the  chorionic  villi,  although  bathed  in  maternal 
blood,  separate  the  latter  from  the  embryonic  blood.  The  vilH  assume  different 
characteristics  at  different  stages  of  development.  At  the  stage  of  formation  of 
the  placenta  at  the  third  month  they  are  irregular,  short,  and  thickset  (Fig.  97). 
Later  they  are  more  regular  and  the  angle  formed  by  the  junction  of  their 
branches  with  the  parent  stem  is  more  obtuse  (Fig.  98).  At  the  close  of  preg- 
nancy their  arrangement  is  more  regular,  while  the  branches  are  less  densely 
crowded  and  far  more  slender  (Fig.  99).  Knowledge  of  the  appearance  of 
the  villi  is  most  important,  since  the  existence  of  pregnancy  is  positively  con- 
firmed by  their  microscopic  detection  in  suspicious  discharges  from  the  vagina. 
The  embedding  of  the  villi  in  the  decidua  is  never  very  intimate,  and  through- 
out their  course  of  development  they  can  be  extricated  with  very  little  difficulty. 


Fig.  ioi. — Ovum  of  Fig.  100  Cut  Open,  showing  Embryo  and  Amnion.     X  2J. — 

{Author's  case.) 

A  large  number  of  the  villi  do  not  penetrate  the  decidua  to  any  depth;  those 
which  are  intimately  joined  to  it  are  called  the  anchoring  or  fastening  villi. 

The  Placenta. — The  placenta  is  the  essential  nutritive  and  respiratory  organ 
of  the  fetus.  It  results  from  the  union  of  the  chorion  frondosum,  q.  v.  (placenta 
foetalis),  and  the  decidua  serotina  (placenta  matemalis).  Formation:  In  addi- 
tion to  the  growth  of  the  chorionic  villi,  q.  v.,  there  are  extensive  changes  in 
the  placental  region  of  the  decidua,  which  also  proliferates  and  forms  septa; 
these,  growing  down  between  the  chorionic  villi,  sometimes  reach  the  surface 
of  the  chorion.  It  is  only  at  the  margins  of  the  placenta  that  the  decidual  septa 
are  well  marked.  Interesting  and  important  formations  in  the  placenta  are 
the  intervillous  spaces.  The  decidua  vera  is  abundantly  supplied  with  a  net- 
work of  blood-vessels  which,  as  we  have  already  seen,  are  entered  by  the  grow- 
ing villi  of  the  chorion.  With  continued  growth  these  open  capillaries  become 
the  intervillous  spaces,  which  are  really  large  sinuses  or  lacunas  of  maternal 
blood,  the  endothelial  cells  of  which  have  disappeared.  As  a  result  of  this 
change  the  branched  chorionic  villi  extend  freely  into  an  almost  continuous 


THE    UMBILICAL  CORD. 


71 


sinus  of  maternal  blood  which  is  bridged  by  villi  (anchoring  villi)  the  tips  of 
which  are  embedded  in  the  decidua.  The  little  curling  arteries,  so  called,  which 
are  derived  from  the  maternal  blood-vessels,  run  along  the  decidual  septa  and 
empty  into  the  sinuses  near  the  chorion.  The  maternal  veins  start  from  the 
bases  of  the  septa,  and  thus  the  circulation  is  maintained  through  the  sinuses. 
Structure:  The  mature  placenta  is  a  flat,  round  or  oval,  sponge-like  body 
which  measures  from  6  to  8  inches  (15  to  20  cm.)  in  diameter  and  0.8  to 
1.2  inches  (2  to  3  cm.)  in  thickness  at  the  central  point,  while  the  margin  is 
about  0.2  inch  (0.5  cm.)  in  thickness.  Its  weight  is  about  a  pound  (500 
grams).  After  expulsion  the  uterine  or  maternal  surface  is  dark  red  and 
granular,  invested  by  a  grayish,  transparent  membrane  consisting  of  the  super- 
ficial layer  of  the  cells  of  the  decidua  serotina,  and  is  marked  by  numerous 
ridges  and  lines  which  divide  it  into  irregular  lobes  called  cotyledons.  These 
number  from  sixteen  to  twenty.  On  this  surface  of  the  separated  placenta 
are  tags  of  tissue  corresponding  to  the  decidual  layer.  The  placenta,  when 
detached  from  its  bed,  shows  the  line  of  demarcation  in  the  spongy  layer 
{q.  V.)  of  the  decidua.  The  fetal  surface, 
smooth  and  shining,  is  covered  by  the 
amnion,  and  the  umbilical  cord  is  attached 
to  its  center.  The  bulk  of  the  organ  is 
spongy  in  character  and  consists  of  the 
tufts  of  chorionic  villi  and  the  intervillous 
spaces  which  are  divided  into  cotyledons, 
above  mentioned,  by  septa  of  connective 
tissue.  After  the  separation  of  the  pla- 
centa from  its  maternal  site  tags  of  de- 
cidua and  chorion  hang  from  the  latter. 
Around  the  peripheral  margin  of  the  pla- 
centa is  sometimes  seen  a  circular  vein, 
the  "circular  vein  of  the  placenta." 
Site:  *  The  placental  site,  as  has  already 
been  described,  is  at  the  junction  of  the 
chorion  frondosum  and  decidua  serotina, 
which  generally  takes  place  near  one  of 
the  tubal  orifices,  although  the  organ 
may  be  found  attached  to  any  point  in 
the  cavity  of  the  uterus.     As  a  rule,  it  faces  the  ventral  surface  of  the  fetus. 

The  Umbilical  Cord. — The  umbilical  cord  is  a  means  of  communication 
between  the  fetal  and  maternal  organisms.  It  is  also  called  the  funis, 
funicle,  or  navel  string.  Origin  and  development:  In  the  human  ovum  the 
mesodermic  connection  of  the  amnion  with  the  chorion,  including  the  rudi- 
mentary allantois,  is  called  the  abdominal  stalk  (Figs.  64  and  65).  With 
the  growth  of  the  body-wall  and  the  extension  of  the  amnion  this  stalk, 
together  with  the  stalk  of  the  umbiHcal  vesicle,  and  the  blood-vessels  which 
unite  the  embryo  with  the  chorion,  become  invested  by  a  continuation  of  the 
somatopleure,  this  whole  forming  the  umbilical  cord  (Fig.  96).  The  umbilical 
vesicle  itself  is  never  included  within  this  cord  (Fig.  96),  but  extends  freely 
beyond  it,  and  by  the  fourth  week  becomes  inconspicuous.  Structure  and 
vessels:  The  epithelium  of  the  cord  consists  not  of  a  single  layer  but  of  several 
layers  of  stratified  epithelium,  continuous  at  the  proximal  end  with  the  epi- 

*  For  the  exact  location  of  the  placenta,  see  Diagnosis  of  Pregnancy,  and  Cassarean 
Section. 


Fig.  102. — Human  Ovum  and  Embryo 
AT  Four  Weeks.  X  2  and  reduced. — 
{Schultze.) 


72 


PHYSIOLOGICAL  PREGNANCY. 


Chorionic  Tu/if^ 


Fig.  103. — Complete  Ovum  and  Decidua  Vera  of  about  the  Sixth  Week.  Shows 
smooth  and  rough  sirrfaces  of  decidua  vera  and  chorion.  Photographed  under  water 
X  2. — {Author's  case.) 


THE    UMBILICAL  CORD. 


73 


dermis    and    at    the    distal    end    with    the    amniotic    epitheUum  •  covering    the 
placenta.     The    cord    is    not    covered    by  the    amnion   throughout  its    entire 


..^iJMi.'iL 


Fig.  104. — Ovum  of  Fig.  ioi  Opened;  shows  Chorion  Removed  Except  at  Site  of  Rudi- 
mentary Placenta  above  and  to  the  Right;  Amnion,  Liquor  amnii,  and  Embryo 
with  Rudimentary  Umbilical  Cord.      X   i^- — (Author's  case.) 


Fig.   105. — Ruptured  Human  Ovum  at  Eight  Weeks.      X    2.     c,  Chorion;    a,  amnion; 
U.C.,  umbilical  cord. — {Schtdtze.) 


extent,  for  this  latter  structure  is  always  separate  from  the  cord   proper.     A 
gelatinous  substance,  Wharton's  jelly,  protects  the  cord  vessels  perfectly  from 


74 


PHYSIOLOGICAL  PREGNANCY. 


Fig.  io6. — Amnion,  Liquor  Amnii,  Embryo,  and  Umbilical  Cord,  about  the  Tenth 

Week.      X  i^. — {Author's  case.) 


,./ 


Fig  107. — Amniotic  Cavity  Inflated,  showing  Maternal  Surfaces  of  Placenta 
and  Amnion  and  Umbilical  Cord  Emerging  from  Cavity  of  Amnion.  Full 
Term. — {From  a  photograph  of  a  fresh  specimen.) 


THE    UMBILICAL   CORD. 


75 


Fig.    io8. — Placenta    and    Unruptured    Membranes    at   the   Thirty-eighth    Week 
(One-third  natural  size.) — {Author's   collection.') 


Fig.  109. — Membranes  of  Fig.  108,  Cut  Open  to  show  Fetus.      Specimen  hardened  in 
formaldehyde  before  rupturing.      (One-third  natural  size.) — {Author's  collection.) 


Fig. 


-Fetal  Surface   of    Placenta 
AT  Term. — (Minot.) 


Fig.  III. — Section  of  Human  Placenta 
OF  Seven  Months  in  situ.  Am.,  Am- 
nion; Cho.,  chorion;  Vi,  trunk  of  villus; 
vi,  sections  of  villi  in  the  substance  of 
the  placenta;  D,  decidua  basalis;  Mc, 
muscularis;  D',' compact  layer  of  decidua; 
Ve.,  uterine  artery  opening  into  the 
placenta.  The  fetal  blood-vessels  are 
drawn  black;  the  maternal  blood-spaces 
are  left  white;  the  chorionic  tissue  is 
stippled  except  the  canalized  fibrin, 
which  is  shaded  by  lines;  the  remnants 
of  the  gland-cavities  in  D^^  are  stippled 
black. — {Minot.') 


Fig.  112. — Connective  Tissue  of  the  Um- 
bilical Cord  of  a  Human  Embryo  of 
about  Three  Months.  X  511  diam- 
eters and  reduced.  Stained  with  alum 
cochineal  and  eosin. — {Minot.) 


Fig.  113. — Cross-section  of  Umbilical 
Cord  at  Term.  X  about  12  diameters, 
y,  Remnant  of  the  allantois;  V,  umbilical 
cord;  A,  A,  umbilical  arteries. — {Minot.) 


Fig.  114. — Transverse  Section  through 
the  Umbilical  Stalk  of  an  Embryo  of 
2.10  MM. — Am.,  Amnion;  m.d.,  medtdlary 
groove;  V,V.,  umbilical  veins;  A. A.,  um- 
bilical arteries;  All.,  allantois;  coe,  coelom. 
{His.) 


76 


THE    UMBILICAL  CORD. 


77 


harmful  pressure.  It  is  derived  from  the  mesodermic  layer  of  the  abdominal 
stalk.  The  gelatin  has  an  irregular  distribution,  being  thicker  in  some  parts, 
where  it  forms  the  so-called  false  knots  in  the  cord.  This  peculiar  substance 
consists  in  great  part  of  embryonic  connective  tissue,  and  is  abundantly 
supplied  with  branching  cells-,  the  protoplasmic  processes  of  which  freely  anas- 
tomose. The  vessels  of  the -funis  are  originally  two  arteries  and  two  veins. 
The  two  veins  fuse  early,  leaving  only  one  (Figs,  no  and  113),  which  comes  to  lie 
between  the  arteries,  so  that  the  funic  pulse  can  be  easily  felt.  The  vessels  are 
coiled  from  right  to  left,  there  being  ten  to  twelve  such  turns.  The  spiral  aspect 
thus  given  to  the  cord  has  been  variously  explained.  One  cause  assigned  is  the  fetal 


Fig.  115. — Section  of  Injected  Full-term  Placenta,  c.s..  Cotyledon  septum;  a., 
amnion;  c,  chorion;  d.s.,  decidua  serotina;  m.i.v.,  muscle  with  injected  vessels. — 
(Leopold.) 


movements;  another,  the  fact  that  the  growth  of  the  blood-vessels  in  length  is 
more  rapid  than  that  of  the  connective  tissue.  The  walls  of  both  arteries  and  vein 
are  of  about  equal  thickness.  The  calibre  of  the  vein  is  in  excess  of  that  of 
the  arteries;  and  while  the  vein  has  semilunar  valves,  the  arteries  have  circular 
valves.  The  length  of  the  cord  averages  about  22  inches  (50  to  60  cm.),  though 
when  very  long  it  may  measure  64  inches  (160  cm.),  while  the  shortest  on  record 
is  4.8  inches  (12  cm.).  Its  diameter  is  from  -|  to  f  of  an  inch  (i.i  to  1.5  cm.). 
The  strength  of  the  cord  varies;  its  tensile  power  at  term  ranging  from  5  to 
12  pounds  (2  to  5  kilograms).  Its  function  is  twofold:  It  carries  nourishment 
from  the  mother  to  the  fetus  as  well  as  waste  matter  from  the  fetus  to  the  pla- 
centa. 


78  PHYSIOLOGICAL  PREGNANCY. 

Nutrition  and  Metabolism  of  the  Ovum,  Embryo,  and  Fetus.* 

Ovum. — The  primordial  human  ovum  in  the  ovary  derives  the  nourishment 
by  which  it  grows  from  the  general  blood  and  lymph  supply  of  the  ovary,  and 
in  so  doing  lays  up  a  small  amount  of  nutriment  in  comparison  with  that  of  the 
germ-yolk  or  deutoplasm  or  food-yolk  (Fig.  96).  It  is  still  an  open  question 
whether  the  follicle-cells  surrounding  the  ovum  contribute  directly  to  its 
nourishment.  As  the  ovum  passes  through  the  oviduct,  as  already  stated,  it  in- 
creases in  size  by  absorption  of  liquid,  which  separates  the  primitive  chorion 
from  the  germ  mass  (Fig.  57).  Later,  and  until  it  possesses  vessels  and  circu- 
lation, it  derives  its  nourishment  from  the  intimate  relations  of  the  chorionic 
villi  with  the  maternal  blood  (Fig.  49).  The  decidua  vera,  by  reason  of  its 
increased  cell-formation,  indicates  the  presence  of  active  metabolism  favorable 
for  the  production  of  nutritive  substances  available  for  the  growing  embryo. 
There  has  been  endless  discussion  concerning  the  intervillous  spaces.  One  theory 
regards  them  as  dilated  uterine  glands  which  secrete  "uterine  milk"  for  nourish- 
ing the  ovum.  It  is  now  known  that  the  glands  become  practically  closed  and 
that  their  ducts  degenerate  before  the  growing  villi. 

During  the  third  week  the  vitelline  or  earliest  embryonic  circulation  develops, 
beginning  in  the  mesodermic  layer  of  the  yolk-sac  in  the  form  of  blood  islands 
(Figs.  65  and  66).  In  the  mean  time  the  original  sparse  food-yolk  has  increased 
in  amount  within  the  yolk-sac,  and  the  blood  islands  unite  to  form  vessels 
which  again  combine  to  form  the  omphalomesenteric  or  vitelline  veins  by  which 
the  contents  of  the  umbilical  vesicle  are  carried  to  the  embryo  proper  for  its 
nourishment.  At  the  same  time  the  heart  and  systemic  vessels  arise  (Figs. 
65  and  70)  and  blood  passes  through  the  vitelline  veins  into  the  sinus  venosus. 
Then,  mixing  with  blood  returned  by  the  systemic  vessels  from  the  body  of  the 
embryo,  it  passes  into  the  single  auricular  segment  or  caudal  end  of  the  tubular 
heart  The  blood  is  conveyed  from  the  anterior  or  arterial  extremity  of  the 
heart  through  the  truncus  arteriosus  to  the  aortic  arches  (Fig.  73);  from  the 
latter  it  flows  into  the  two  primitive  aortas.  The  smaller  quantity  is  carried 
into  vessels  which  nourish  the  embryo,  while  the  greater  portion  reaches  again 
the  vascular  area  by  the  vitelline  arteries.  Thus  a  complete  circulation  in 
closed  vessels  is  formed  for  the  nourishment  of  the  embryo. 

True  Chorion. — The  development  of  this  organ  has  already  been  described. 
The  villi,  hollow  at  first,  are  invaded,  soon  after  their  appearance,  by  mesoderm 
and  then  by  blood-vessels  derived  from  others  which  grow  out  along  the  abdom- 
inal stalk.  With  the  development  of  these  vessels  the  primitive  chorionic  circu- 
lation is  established,  which  rapidly  supersedes  the  vitelline.  With  the  distinct 
localization  of  the  placenta  this  becomes  the  placental  circulation.  After  the 
earlier  stages  of  development,  all  the  returning  placental  blood  passes  through 
the  liver  on  its  way  to  the  heart,  but  when  the  placental  circulation  becomes 
more  extensive  the  extra  work  is  assumed  by  the  development  of  the  ductus 
venosus,  through  which  a  considerable  amount  of  blood  passes  directly  into 
the  inferior  vena  cava  without  traversing  the  liver  (Figs.  100,  loi,  102,  and  103). 

Functions  of  the  Placenta. — The  placental  functions  are  varied,  and  it  may 
be  stated  in  general  that  it  assumes  the  role  of  several  other  organs,  the  lung 
or  gill,  the  alimentary  tract,  liver,  and  kidney.     It  aerates  the  fetal  blood, 

*  The  term  ovum,  as  here  used,  indicates  not  only  the  unfertilized  egg,  but  also  the 
fertilized  egg  and  the  early  stages  of  its  development;  it  therefore  includes  not  only  the 
embryo  but  the  membranes.  The  term  fetus  is  used  to  designate  somewhat  loosely  the 
later  stages  of  the  developing  organism. 


NUTRITION  OF  THE  OVUM,  EMBRYO,  AND   FETUS.  79 

supplying  it  with  oxygen  so  that  it  is  the  respiratory  organ  of  the  fetus.  It 
absorbs  nutriment  from  the  maternal  blood,  thus  playing  the  part  of  the 
mature  alimentary  tract.  It  has  been  shown,  according  to  Bernard,  to  possess 
a  glycogenic  function  analogous  to  that  of  the  liver.  It  also  serves  the  pur- 
pose of  an  excretory  organ,  eliminating  not  only  the  carbon  dioxid  but  other 
abundant  waste  products  of  .the  fetal  metabolism.  Interesting  work  has  been 
done,  showing  the  peculiar  selective  power  possessed  by  the  epithelial  cells  of 
the  chorionic  villi.  They  eliminate  the  carbon  dioxid  of  the  fetus,  and  if  the 
interchange  of  gases  were  reversed,  the  villi  absorbing  carbon  dioxid  from  the 
maternal  blood,  this  would  prove  fatal  to  the  fetus. 

Fetal  Blood. — In  the  early  months  of  gestation  the  fetal  blood  contains 
nucleated  red  blood-corpuscles,  sharply  distinguishable  from  those  of  the  mother. 
At  first  these  are  few  in  number,  but  increase  very  rapidly;  so  that  in  well- 
preserved  specimens  the  vessels  are  large,  conspicuous  objects  and  are  crowded 
with  corpuscles.  At  about  the  third  month  the  majority  of  these  cells  have 
been  replaced  by  non-nucleated  corpuscles  similar  to  those  of  the  adult.  The 
relative  quantity  of  blood  in  the  fetus  and  placenta  undergoes  considerable 
variation,  the  placenta  at  first  having  the  larger  amount;  later  the  fetus  and 
placenta  contain  about  equal  amounts,  while  still  later  the  quantity  in  the  fetus 
exceeds  that  in  the  placenta.  The  fetal  arterial  blood-pressure  is  about  half 
that  of  the  newly  born  child,  while  the  venous  pressure  is  much  higher.  The 
velocity  of  the  blood  in  the  umbilical  arteries  is  far  slower  than  in  adult  arteries 
of  similar  calibre.  The  fetus  eliminates  about  the  same  volume  of  carbon 
dioxid  as  it  absorbs  of  oxygen.  This  latter  amount  is  about  one-fourth  that 
used  by  the  maternal  organism,  and  the  amount  of  gas  concerned  in  the  pla- 
cental system  is  about  one-half  that  which  is  used  in  the  lung  during  respiration. 
In  this  way  the  slight  metabolism  of  the  fetus  is  explained;  consequently  when 
the  communication  with  the  mother  is  severed,  the  possibility  of  survival  is 
longer,  and  is  not  followed  by  immediate  suffocation,  while  it  also  accounts 
for  the  slight  difference  in  temperature  of  mother  and  child. 

Kidney  Excretion. — The  kidneys  begin  to  assume  functional  form  at  the 
seventh  week.  At  first  their  ducts  communicate  with  the  rudimentary  allan- 
tois,  but  since  the  bladder  is  derived  from  this  organ,  the  ureters  finally  empty 
into  that  viscus.  In  the  course  of  development  urine  is  excreted  by  the  fetus 
from  time  to  time,  as  can  be  proved  by  the  presence  of  urea  in  the  amniotic 
fluid.  There  is  always  a  certain  amount  of  albumin  in  the  fetal  urine.  There 
is  a  specially  important  medico-legal  point  in  connection  with  the  appearance 
of  the  kidneys:  it  is  the  formation  of  dark  yellow  infarcts,  which  are  invariably 
present  even  if  the  infant  has  breathed  but  for  a  very  short  time  before  death. 
Their  causation  is  not  known. 

Bowel  Excretion. — The  bowels  are  normally  inactive  in  intrauterine  life, 
although  in  pathological  conditions — e.  g.,  apoplexy,  coiled  cord,  compressed 
cord,  etc. — there  may  be  a  discharge  of  meconium.  This  should  be  a  danger- 
signal  when  occurring  in  labor,  unless  there  is  a  breech  presentation. 

The  Fetal  Circulation. — As  stated  in  the  section  on  nutrition,  the  first  signs 
of  the  blood  and  blood-vessels  in  the  embryo  are  the  blood  islands  in  the  um- 
bilical vesicle.  The  heart  in  reptiles,  birds,  and  mammals,  so  far  as  has  been 
sufficiently  determined,  has  been  found  to  develop  as  two  independent  tubes 
in  the  visceral  layer  of  the  splanchnopleure  of  the  neck  region.  As  the  two 
visceral  layers  fold  over  the  ventral  side  of  the  embryo  and  fuse,  the  double 
heart  also  fuses  to  form  a  single  tubular  heart.  The  separation  into  auricles 
and  ventricles  of  a  right  and  a  left  heart  is  due  to  the  growth  of  valves  and  par- 


80 


PHYSIOLOGICAL  PREGNANCY. 


Fig.  ii6. — The  Fetal  Circulation,  ao,  Aorta;  a.pu,  pulmonary  artery;  au,  umbilical 
artery;  da,  ductus  arteriosus;  dv,  ductus  venosus;  int,  intestine;  vci  and  vcs,  inferior 
and  superior  vena  cava;  vh,  hepatic  vein;  vp,  vena  portae;  v.pu,  pulmonary  vein;  vu, 
umbilical  vein. — (From  Kollmann.) 


NUTRITION  OF   THE  OVUM,  EMBRYO,  AND   FETUS.  81 

titions  in  this  single  tubular  heart.  From  the  cephalic  end  of  the  primitive 
tubular  heart  extend  two  primitive  aortas,  and  from  the  caudal  or  venous  end 
extend  the  two  vitelline  veins.  All  of  the  subsequently  developed  arteries 
and  veins  are  likewise  in  pairs  except  the  posterior  cava  (inferior  vena  cava). 
The  adult  condition  of  the  vascular  system  is  attained  by  two  processes:  viz., 
suppression  and  fusion.  The  suppressions  and  fusions  are  shown  in  part  in 
Figs.  73  and  74.  Advancing  from  the  primitive  embryonic  condition,  the  vessels 
of  the  allantois  and  placental  circulation  soon  cause  the  development  of  a 
more  complicated  system,  in  which  the  heart  and  liver  play  important  rdles. 
In  the  later  months  of  pregnancy  the  blood,  laden  with  nutriment  for  the 
developing  fetus,  collects  from  the  ultimate  venous  rootlets  in  the  chorionic  villi 
and  ultimately  finds  its  way  to  the  (i)  umbilical  vein.  At  first  there  are  two 
umbilical  veins,  but  soon  the  right  fuses  with  the  umbilical  cord  and  only  the 
left  persists.  This  enters  by  way  of  the  umbilical  cord,  passes  first  to  the  navel, 
and  thence  upward  along  the  free  suspensory  ligament  of  the  (2)  liver  to  the 
under  surface  of  this  organ,  where  it  subdivides  into  several  branches.  Two 
of  these  go  to  the  left  lobe  and  the  others  to  the  lobus  quadratus  and  the  lobus 
Spigelii.  The  vein  again  subdivides  at  the  transverse  fissure  into  two  branches, 
the  larger  of  which,  joining  with  the  portal  vein,  penetrates  the  right  lobe.  The 
smaller,  as  the  (3)  ductus  venosus,  or  duct  of  Arantius,  passes  on  across  the 
inferior  hepatic  surface  until  it  meets  the  (4)  left  hepatic  vein  just  at  that  point 
where  the  latter  vessel  joins  the  (5)  inferior  vena  cava.  The  blood  which  circu- 
lates through  the  liver  undoubtedly  undergoes  certain  changes  in  metabolism, 
and  finally  collects  again  in  the  hepatic  vein,  through  which  it  flows  to  the 
ascending  vena  cava.  Thus  there  are  two  avenues  through  which  the  blood, 
flowing  through  the  umbilical  vein,  reaches  the  inferior  vena  cava;  the  greater 
part,  together  with  the  portal  venous  blood,  circulating  through  the  liver,  pre- 
vious to  entering  the  vena  cava  by  the  hepatic  vein.  The  remainder  goes 
directly  to  the  vena  cava  by  the  union  of  the  ductus  venosus  and  the  left  hepatic 
vein.  The  blood  coming  from  the  ductus  venosus  and  hepatic  veins  mingles 
in  the  inferior  vena  cava  with  that  from  the  lower  extremities  and  the  abdominal 
viscera.  It  flows  into  the  (6)  right  auricle,  and,  directed  by  the  (7)  Eustachian 
valve,  it  courses  through  the  (8)  foramen  ovale  into  the  (9)  left  auricle.  Here 
it  joins  a  little  blood  that  has  come  from  the  lungs  by  the  pulmonary  veins. 
It  then  flows  from  the  left  auricle  to  the  (10)  left  ventricle,  and  thence  into  the 
(11)  aorta,  by  which  it  is  in  great  part  taken  to  the  (12)  upper  extremities  and 
(13)  head.  A  little  passes  down  by  the  (14)  descending  aorta.  The  blood  from 
the  head  and  upper  extremities  is  collected  by  the  (15)  venous  radicles  and  finally 
reaches  the  branches  of  the  (16)  superior  vena  cava,  known  in  earlier  stages  of 
development  as  the  right  duct  of  Cuvier.  This  is  formed  by  the  junction  of  a 
superior  vein  (the  primitive  jugular)  and  an  inferior  cardinal  vein,  the  corre- 
sponding left  duct  disappearing  in  the  process  of  development.  The  superior 
vena  cava  empties  into  the  (17)  right  auricle,  where  it  mingles  with  a  small 
quantity  from  the  inferior  vena  cava;  it  then  passes  over  the  Eustachian  valve 
into  the  (18)  right  ventricle,  and  thence  into  the  (19)  pulmonary  artery.  Since 
the  fetal  lungs  are  solid  and  almost  impervious,  but  a  small  portion  of  the  blood 
from  the  pulmonary  arteries  passes  to  them  and  is  then  returned  by  the  pul- 
monary veins  to  the  left  auricle.  The  greater  quantity  flows  through  the  (20) 
ductus  arteriosus,  rediClung  by  this  channel  the  (21)  descending  aorta  (see  14), 
where  it  joins  the  small  part  of  the  blood  from  the  left  ventricle  which  has  also 
passed  into  this  artery.  It  now  descends  to  supply  the  (22)  abdo^ninal  and 
pelvic  viscera  and  the  (23)  lower  extremities,  although  its  greater  part  flows 
6 


82  PHYSIOLOGICAL  PREGNANCY. 

through  the  (24)  hypogastric  arteries  to  the  (25)  umbilical    arteries  and    the 
(26)  placenta. 

Peculiarities  of  the  Fetal  Circulation. — Several  facts  stand  out  with 
special  clearness  in  this  process  of  fetal  circulation:  (i)  The  duplex  function 
of  the  placenta — respiration  and  nutrition.  In  this  organ  the  venous  or  impure 
blood  is  oxygenated  and  surcharged  with  nutriment,  and  returns  to  nourish 
the  fetus.  (2)  By  far  the  greater  part  of  the  blood  of  the  umbilical  vein  circu- 
lates through  the  fetal  Hver,  which  fact  accounts  for  the  very  large  size  of  that 
organ,  especially  in  early  fetal  existence.  (3)  The  right  auricle  is  the  meeting- 
place  for  a  dual  current,  that  from  the  inferior  vena  cava  being  guided  by  the 
Eustachian  valve  into  the  left  auricle,  while  the  blood  coming  from  the  upper 
extremities  and  the  head  descends  from  the  right  auricle  into  the  right  ventricle. 
In  early  stages  the  entrance  of  the  ascending  vena  cava  is  almost  directly  into 
the  left  auricle,  so  that  there  is  probably  little  or  no  mingling  of  the  two  streams, 
but  later  the  two  auricles  are  more  definitely  separated  and  a  certain  mixing  of 
the  two  currents  occurs.  The  blood  from  the  placenta,  together  with  that 
from  the  ascending  cava,  is  carried  through  the  left  heart  almost  directly  to  the 
aortic  arch,  whence  it  proceeds  by  means  of  the  large  aortic  branches  which 
are  given  off  near  the  heart  to  the  head  and  upper  extremities,  thus  accounting 
for  the  extremely  well-developed  condition  of  these  parts;  while  the  blood  that 
has  already  circulated  in  the  upper  parts,  being  thereby  deprived  of  most  of 
its  nutriment,  is  carried,  together  with  a  small  part  from  the  left  ventricle,  to 
the  viscera  and  lower  extremities;  and  this  fact  consequently  accounts  for  the 
small  size  and  poor  state  of  development  of  the  latter. 

Characteristic  Features. — The  characteristic  features  of  the  fetal  cir- 
culation are  (i)  the  ductus  venosus,  (2)  the  ductus  arteriosus,  (3)  the  foramen 
ovale,  (4)  the  hypogastric  arteries,  and  (5)  the  umbilical  vein.  After  birth 
circulation  and  respiration  take  place  as  in  the  adult,  although  the  changes 
leading  to  the  complete  functional  development  of  the  systems  and  the  atrophy 
of  the  fetal  structures  take  a  considerable  period  of  time. 

The  Earliest  Human  Ovum. — The  earliest  ovum  in  an  apparently  normal  con- 
dition is  that  described  and  figured  by  Peters  in  1899  (Fig.  51).  It  was  sectioned 
with  a  portion  of  the  uterine  wall  in  which  it  was  partially  embedded.  The 
extreme  limits  of  the  ovum  are  about  0.12  X  0.06  X  0.06  inch  (3  X  1.5  X 
1.5  mm.),  in  the  form  of  a  flattened  sphere.  The  outer  surface  or  chorion  is 
covered  by  villi,  and  it  is  found  that  it  is  a  hollow  sac,  the  cavity  of  which 
measures  0.064  X  0.032  X  0.036  inch  (1.6  X  0.8  X  0.9  mm.).  Within  the  sac 
of  the  chorion  and  attached  to  one  side  is  a  cellular  mass  about  0.008  inch  (0.2 
mm.)  in  diameter  and  containing  two  cavities.  The  cavity  lying  nearer  the 
chorion  is  the  amnion ;  the  other  cavity  is  the  yolk  or  umbilical  sac.  The  amnion 
is  formed  as  a  closed  sac  of  a  single  layer  of  cells  which  are  elongated  on  the 
side  away  from  the  chorion ;  i.  e.,  in  that  part  where  from  later  stages  it  is  known 
the  embryo  will  be  formed.  The  yolk-sac  is  lined  by  entodermal  cells,  and 
between  it  and  the  above-mentioned  thickened  ectodermal  cells  is  a  layer  of 
mesoderm  which  not  only  lies  between  ectoderm  and  entoderm,  but  completely 
envelops  the  yolk-sac  and  the  amniotic  sac  and  forms  a  connection  between 
these  and  the  chorion  and  then  forms  a  complete  lining  for  the  chorion.  Thus 
it  is  seen  that  in  this  early  human  embryo,  in  which  the  body  is  represented 
by  a  flat  or  concave  disc  of  ectoderm,  a  layer  of  mesoderm,  and  a  sac  of  ento- 
derm, the  relative  rate  of  development  of  parts  has  been  quite  different  from 
that  described  above  for  the  rabbit.  This  difference  becomes  more  apparent 
when  the  membranes  are  discussed.     But  it  is  seen  that  there  is  essential  unity 


CHARACTERISTICS  OF  THE  OVUM,  EMBRYO,  AND   FETUS.     83 

in  the  fact  that  the  three  germ-layers  exist.  Just  how  they  arise  in  man  must 
await  solution  until  still  younger  human  embryos  are  as  carefully  preserved  and 
studied  as  was  Peters 's  specimen. 

Characteristics  of  the  Ovum,  Embryo,  and  Fetus  in  the  Several  Lunar  Months 
of  Gestation. — These  are  of  value  to  enable  us  to  determine  the  exact  period 
of  gestation,  the  cause  of  the  premature  interruption  of  pregnancy,  the  clew 
to  many  congenital  deformities  and  intrauterine  diseases  and  accidents,  and 
tests  of  maturity. 

Embryos  of  the  First  Month. — The  size  of  the  ovum  described  bv 
Peters  is  0.12  X  0.06  X  0.06  inch  (3  X  1.5  X  1.5  mm.);  and  of  the  em- 
bryonic area  about  0.0076  inch  (0.19  mm.).  The  chorion  is  hollow  with  a 
mesodermic  lining  and  solid  epithelial  villi.  The  amniotic  sac  is  formed  and 
the  embryonic  area  is  merely  a  thickened  portion  of  this  sac.  The  yolk-sac 
is  larger  than  that  of  the  amnion.  The  embryonic  mass  is  attached  to  the 
chorion  by  a  wide  mesodermic  connection  which  completely  separates  the 
latter  from  the  amniotic  epithelium.  Spec's  specimen  (Fig.  64)  measures  0.28 
X  0.22  inch  (7  X  5.5  mm.),  and  the  embryo  0.0148  inch  (0.37  mm.).  The  meso- 
dermic connection  of  embryonic  mass  with  the  chorion  is  narrower  and  blood 
islands  have  appeared  on  the  yolk-sac.  In  Etemod's  specimen  the  chorion 
measures  0.432  X  0.328  X  0.24  inch  (10.8  X  8.2  X  6  mm.)  and  the  embryo 
0.052  inch  (1.3  mm.).  The  embryonic  area  is  somewhat  elongated  and  shows 
a  neural  groove  and  neurenteric  canal.  The  heart  is  at  the  extreme  cephalic 
end  of  the  embryonic  area.  Vascular  connections  are  established  between 
yolk  and  embryo  and  also  with  the  chorion.  In  Spee's  specimen  (Fig.  65), 
measuring  0.072  X  0.06  inch  (1.8  X  1.5  mm.)  with  embryo  0.0616  inch  (1.54 
mm.),  the  chorionic  villi  are  already  branched  with  mesoderm  penetrating 
them.  The  allantoic  rudiment  extends  into  the  abdominal  stalk,  but  heart  and 
blood-vessels  do  not  seem  to  be  so  far  advanced  as  in  Eternod's  smaller  specimen. 
At  the  end  of  the  third  week  (Figs.  100  and  loi)  the  ovum  measures  about 
I  X  0.8  inch  (25  X  20  mm.)  and  the  embryo  0.16  to  0.2  inch  (4  to  5  mm.). 
The  villi  are  distinctly  branched.  The  embryo  is  well  outlined;  head,  trunk, 
tail,  and  limbs  are  recognizable.  The  neural  tube  is  completely  closed  and  dif- 
ferentiation into  brain  and  eye  vesicles  has  begun.  The  internal  ear  is  a  closed 
vesicle.  The  nasal  epithelium  is  a  thickened  disc.  The  mouth  connects  with 
the  pharynx,  in  which  are  four  branchial  clefts.  The  alimentary  canal  is  a 
straight  tube  except  for  the  wide  connection  with  the  yolk-sac  and  its  ap- 
pendages; thyroid,  thymus,  lungs,  and  liver  are  recognizable.  The  heart  tube 
has  assumed  the  characteristic  S-shaped  twist,  and  though  divided  into  auricular 
and  ventricular  portions,  is  not  separated  into  right  and  left  halves.  The 
mesonephros  (primitive  kidney)  is  prominent.  The  somites  are  numerous  and 
distinct.  The  limbs  form  bud-like  projections.  In  other  words,  during  the  third 
week  the  majority  of  the  organs  take  on  recognizable  features  (Figs.  75,  76,  77, 
and  78). 

End  of  First  Month  or  Fourth  Week. — Characteristics  of  ovum:  Waldeyer's 
classical  description  of  an  ovum  four  weeks  old  gives  its  size  as  that  of  a  pigeon's 
egg;  in  length  f  inch  by  f  inch  broad  (20  X  16  mm.).  (Mall  gives  1.12  X  0.8 
inch — 28  X  20  mm. — for  an  embryo  of  twenty-seven  days.)  Its  weight  was  34.5 
grains  (2.3  grams).  The  chorion  is  a  flattened  vesicle  containing  fluid  and  is 
made  up  of  two  walls.  The  inner  wall  is  smooth  while  the  outer  one  bears  the 
branching  villi.  It  is  not  firmly  embedded  in  the  uterine  tissue  and  its  separa- 
tion can  easily  take  place.  The  yolk-sac  is  larger  than  the  cephalic  extremity 
of  the  embryo  and  its  stalk  is  enclosed  in  the  umbilical  cord.     A  clear  space 


84  PHYSIOLOGICAL  PREGNANCY. 

separates  the  chorion  from  the  amnion,  which  remains  close  to  the  embryo. 
The  embryo  and  chorion  are  connected  by  blood-vessels  which  do  not  penetrate 
the  villi  (Fig.  102). 

Characteristics  of  the  embryo:  At  this  period  the  human  embryo  can  be  dis- 
tinguished from  that  of  any  other  mammal  only  with  great  care.  It  is  much 
curved,  head  and  tail  being  close  together,  and  is  \  inch  long  (7  to  8  mm.);  or, 
taking  the  vertex-coccygeal  length,  i  inch  (20  mm.).  Weight,  20  grains  (1.30 
grams).  The  cerebral  vessels  are  present,  and  the  brain  and  spinal  cord  are 
enclosed.  The  eye  and  ear  vesicles  can  both  be  distinguished  and  the  nasal 
epithelium  forms  a  slight  pit.  Only  three  branchial  clefts  are  clearly  seen. 
The  tongue  is  a  mere  rudiment  and  the  mouth  is  perforate.  The  liver  shows 
marked  growth  and  the  kidneys  appear  about  this  time,  with  the  beginnings 
of  the  pancreas.  The  heart  is  very  prominent  and  its  division  into  four  cavities 
has  begun.  It  has  probably  assumed  its  function  by  the  third  week.  It  is 
covered  by  the  pericardium.  The  rudimentary  extremities  are  still  bud-like 
(Figs.  78  and  79). 

End  of  Second  Month  or  Eighth  Week. — Characteristics  of  ovum:  The 
ovum  at  the  end  of  the  second  month  is  as  large  as  a  hen's  egg.  It  is  about 
2  inches  (5  cin.)  long  by  if  inches  (4  cm.)  wide.  Its  weight  is  from  330  to 
375  grains  (22  to  25  grams).  About  the  middle  of  this  month  there  is  a  more 
luxuriant  growth  of  the  villi  at  one  part  on  the  chorion  marking  the  origin  of 
the  placenta.  Instead  of  obtaining  nourishment  from  the  umbilical  vesicle, 
the  fetus  now  depends  wholly  on  the  maternal  blood  for  its  food.  The  um- 
bilical vesicle  is  much  smaller  proportionally  and  is  attached  to  the  embryo 
by  a  slight  pedicle.  The  amnion  is  distended  with  fluid  but  is  not  yet  in  con- 
tact with  the  chorion  (Figs.  103  and  105). 

Characteristics  of  the  embryo:  The  vertex-coccygeal  length  is  about  an  inch 
(2.5  cm.),  the  total  length  being  about  the  same.  Its  weight  is  nearly  60  grains 
(4  grams).  The  head  is  about  as  large  as  the  trunk.  The  neck  is  formed.  All 
the  visceral  clefts  except  the  first  are  closed.  This  latter  forms  the  external 
auditory  meatus,  tympanum,  and  Eustachian  tube.  The  superior  and  inferior 
maxillary  processes  are  formed.  Bone  nuclei  appear  in  the  clavicles  and  lower 
jaw.  The  salivary  glands  and  dental  groove  are  formed.  There  is  decrease 
in  the  size  of  the  wide  oral  opening.  According  to  His,  the  embryo  is  trans- 
formed into  the  fetus  when  it  has  reached  a  length  of  about  0.6  to  0.64  inch 
(15  to  16  mm.);  for  at  this  stage  the  shape  of  the  head  and  the  articulation  of 
the  extremities  are  distinctly  of  the  human  type,  and  the  tail  has  nearly  dis- 
appeared. The  hands  and  feet  are  webbed  at  first.  The  eyes,  ears,  and  nose 
can  be  clearly  made  out.  The  brain  vesicles,  although  exhibiting  large  cavities, 
are  developing  and  increasing  the  size  of  the  head.  The  body  begins  to  straighten 
a  little  from  the  growth  of  the  viscera.  The  cord  is  somewhat  longer,  and 
although  the  umbilical  ring  is  contracted  to  some  extent,  there  are  still  a  few 
loops  of  intestine  in  it.  The  AVolffian  bodies  are  smaller,  but  the  kidneys  and 
suprarenal  bodies  are  developed.  Although  the  external  genitals  are  now 
apparent,  the  sex  cannot  be  distinguished,  for  the  elements  of  both  sexes  are 
equally  present  (Fig.  81). 

End  of  the  Third  Month  or  Twelfth  Week. — Characteristics  of  ovum: 
The  ovum  is  about  the  size  of  a  goose-egg.  It  averages  4|- inches  (11  cm.)  in 
length.  The  placenta,  though  small,  is  now  complete,  and  the  chorion  loses  its 
villi  except  at  this  point.     The  amnion  is  in  contact  with  the  chorion. 

Characteristics  of  the  fetus:  The  vertex-coccygeal  length  of  the  fetus  is  3.2 
inches  (7  to  8  cm.),  while  the  total  length  is  4  inches  (10  cm.).     It  weighs  about 


CHARACTERISTICS  OF  THE  OVUM,  EMBRYO,  AND  FETUS.       85 

450  grains  (30  grains).  The  cord,  as  it  lengthens  out,  begins  to  make  spiral 
turns,  while  the  umbilical  ring  narrows  and  the  intestines  are  now  wholly  within 
the  abdomen.  The  sex  can  be  distinguished  by  the  appearance  or  absence 
of  a  uterus.  The  scrotum  -and  labia  majora  are  composed  of  skin  folds  and 
the  penis  and  clitoris  are  equal  in  length.  The  nails  are  fine  membranes,  and 
the  webbed  appearance  of  the  fingers  and  toes  disappears.  Nearly  all  the 
bones  present  points  of  ossification.  The  neck  is  longer,  while  the  ribs  mark 
the  line  of  division  between  the  abdomen  and  chest.  The  palate  is  formed 
between  the  oral  and  nasal  cavities.  Teeth  are  forming  and  lips  close  the 
mouth.  The  eyes  are  relatively  nearer  together  and  become  covered  by  the 
lids.     The  proctodeal  or  anal  opening  is  perforate  (Fig.  82). 

End  of  the  Fourth  Month  or  Sixteenth  Week. — Characteristics  of  the 
fetus:  The  fetus  is  3  inches  long  (7.62  cm.)  from  coccyx  to  vertex,  the  entire 
length  being  5  inches  (12.7  cm.).  The  weight  is  1800  grains  (120  grams).  The 
placenta  continues  to  grow  and  the  cord  becomes  more  spiral  in  form.  The 
sex  is  clearly  defined.  Lanugo  develops.  There  is  meconium  in  the  intestines. 
The  umbilical  cord  is  thicker  on  account  of  the  beginning  formation  of  Wharton's 
jelly  (Fig.  83). 

Vitality:  There  may  be  feeble  movements  of  the  limbs,  and  if  the  child  is 
bom  it  may  live  some  hours,  endeavoring  during  this  time  to  breathe. 

End  of  the  Fifth  Month  orTwentiethWeek. — Characteristics :  TheYertex- 
coccygeal  length  is  4.5  inches  (10.16  cm.),  the  total  length  8  inches  (20.32  cm.). 
The  weight  is  4095  grains  (273  grams).  The  cord  is  about  12  inches  (30  cm.) 
long.  Here  and  there  are  patches  of  vernix  caseosa.  The  face  is  wrinkled 
and  has  a  senile  appearance.  The  eyelids  are  opening.  The  head  is  huge, 
comparatively.  There  is  more  fat  on  the  body  (Fig.  134). 
,  Vitality:  It  is,  as  a  rule,  during  the  fifth  month  that  the  mother  feels  quicken- 
ing. The  fetal  heart  sounds  are  audible.  If  born  at  this  time,  the  fetus  gener- 
ally dies  at  once,  though  it  may  live  a  few  hours.  It  may  breathe  and  cry 
(Figs.  83  and  130). 

End  of  the  Sixth  Month  or  Twenty-fourth  Week. — Characteristics:  The 
■fetus  is  6.15  inches  (15.87  cm.)  long  from  vertex  to  coccyx,  with  a  total  length 
of  12.20  inches  (31. 11  cm.).  It  weighs  i^  pounds  (680  grams).  The  skin  is 
richer  in  fat,  the  hair  on  the  head  grows.  There  are  distinct  brows  and  lashes. 
The  head  is  large.  The  cord  is  midway  between  the  symphysis  and  the  xiphoid 
cartilage.     The  testicles  approach  the  inguinal  rings. 

Vitality:  A  fetus  born  at  this  time  might  live  for  fifteen  days,  but  it  would 
finally  die  from  insufficient  air-supply,  for  the  finer  air-passages  are  yet  un- 
developed. There  would  also  be  imperfect  assimilation  of  food  and  rapid  loss 
of  heat. 

End  of  Seventh  Month  or  Twenty-eighth  Week. — Characteristics:  The 
vertex-coccygeal  length  is  now  about  8  inches  (20.32  cm.),  the  total  length 
14.4  inches  (36.19  cm.),  and  the  weight  has  reached  2^  pounds  (iioo  grams). 
The  pupillary  membrane  disappears.  There  is  considerable  meconium  in  the 
large  intestine.  Lanugo  covers  the  body  except  the  palms  of  the  hands  and 
the  soles  of  the  feet. 

Vitality: '  A  child  born  about  this  time  very  seldom  survives.  However, 
no  effort  should  be  spared  to  save  life,  for,  according  to  Lusk,  it  may  be  owing 
to  the  skepticism  of  the  physician  in  regard  to  the  viability  of  these  infants 
that  so  many  have  died. 


Shape  of  Uterus. 

Marked       antero-posterior 
growth.    Pyriform  shape. 

Pyriform    shape   still   pre- 
served but  almost  cylin- 
drical. 

Pyriform  shape  disappear- 
ing.     Shape  now  nearly 
spherical. 

Marked    ovoid.       Anterior 
surface    rounded    like    a 
ball.       Posterior    surface 
flattened.      Tubes  below 
horns. 

Shape  same  as  at  end  of 
fovu"th  month. 

Ovoid  of  4  and   5  months 
gradually  becoming  egg- 
shaped.       Posterior    wall 
flattened    by    spinal    col- 
umn.    Tubes  well  below 
horns. 

Size  of  Uterus. 

ix         '      gJC                    '      i^         '      g'X 

x^-^        xx-j                 ^              ^H^ 

x.2"^      X2y            X--  '  x:?o 

CO              1      ■*                           1      "^              !     ^ 

■;:?              -"^ 

XX?        ^xg 

vo  m                ^  c  '^ 

•    vo                          •    w 

X  M  oi           X  J;; 

J  o   . 

oi 

H 
U 

b 
0 
H 

X 

o 

3 

s 

r»-. 

77.16  to  308.64  gr. 
(5  to  20  grams) 

1.94  to  4.23  oz.   (55 
to  120  grams) 

"In 

i 

0 

00 

<s 

N 

0 

00 

dv 

vo 

B 

Total  Length  of 
Fetus. 

■ 

■ 

2-75   to   3.54  in.    (7 
to  9  cm.) 

3.94  to  6.69  in.  (10 
to  17  cm.) 

7.08  to  10.62  in.  (18 
to  27  cm.) 

00? 
^  0 

^^ 

0   0 

00 

H 

Vertex-coccygeal 
Length  of  Fetus. 

^_^00 

B^ 

d'^s 

•2  o  2 

d  d 

0.33  to  0.5  in.  (0.85 

to  1.28  cm.) 
0.51  to  0.67  in.  (1.3 

to  1.7  cm.) 
0.63  to  0.82  in.  (1.6 

to  2.1  cm.) 

0.82  to  2.68  in.  (2.1 
to  6.8  cm.) 

2.71  to  3.54  in.  (6.9 
to  9.0  cm.) 

3.82  to  5.79  in.  (9.7 
to  14.7  cm.) 

5.9  to  7.36  in.  (15.0 
to  18.7  cm.) 

Pregnancy. 

3d  week 
4th  week 

5  th  week 

6th  week 

7th   and 
8th  weeks 

12  th  week 
1 6th  week 

20th  week 
24th  week 

0 
Q 
0 

5 
u 

Oh 

ist 
month 

2d 
month 

3d 
month 

4th 
month 

-^B 

6th 
month 

■SNOi.i.'aoav 


86 


■(saovi'aavDSiPM)  s^oavn  a^inxvivHi 


Distinctly    egg-shaped. 
Broadest  portion  just  be- 
low ftmdus.  Longitudinal 
axis  predominates.     Pos- 
terior   surface    flattened 
by  spinal  column.    Tubes 
well  below  horns. 

Shape  same  as  at  end  of 
seventh  month. 

Ovoid  shape.    Longitudinal 
axis  predominates.    Ftm- 
dus broad.     Posterior  de- 
pression caused  by  lum- 
bo-sacral  angle. 

Ovoid     shape.          Fundus 
rarely    regular    and    de- 
pends    on      posttire      of 
fetus.    Fetal  head  causes 
increased  development  of 
anterior    part     of    lower 
portion  of  uterus,  causing 
sacciform     dilatation     of 
lower  uterine  segment. 

VO   '^    N 

x-^ 

IN 

'♦'NO  X 
t^  IN   ^ 

x^lC- 

M 

XxS 

HM            IT) 

00   10    • 

^00 

-^X 

w 

to  10 

CO           (J 
XX-r: 
Hn  0      • 

ONUp« 

X  " 

2f   in.    (6.98 

cm.) 

00 

ON 

-  no' 

<N 

01         10 

NO           M 

t^           00' 

•si-^? 

fO        fO 

0\          M 
00         10 

00'          On 
ro        CO 

0 
0 
w 

H 

m' 

;ri  C                t--  CO 

".ON               !       ^     &) 

0                  J^O 
0    0             .        lONO 

+^0               0  "^ 

NO                              +J 

ro                 1       ro 

to'  0 

'0 

-tJ  0 
0 

0° 

NOW 

NO 

NO  B 
On  0 

4oo 
'^    fO 

0  0 

00    ro 
00  V-' 

.B               ^ 

i             NO                             On-'-v 

NO   00                                0 

ON^                   irjO 

-t                                  NO 

M                           1          M 

00 

.s 

00                            1 

0 

06 

li    • 

od°° 

00   C 

0  -^ 

P) 

■^B 
00  0 

On 

M 

.s 

H 
OOO 

M     0 
0     0 
^    fO 

'^  ^ 

NO     0 

■  -IJ 
0 

M 

.B 
2°     ( 

H     0 
00^ 

M 

H 

28th  week 

29th  week 
32d  week 

34th  week 
36th  week 

i     :S     ^ 
t^     0 

1         CO        I* 

-1 
-1 

00  0 

0  0 

•saoevT  synxvKa^d 


87 


88  PHYSIOLOGICAL  PREGNANCY. 

End  of  the  Eighth  Month  or  Thirty-second  Week. — Characteristics:  The 
vertex-coccygeal  length  is  10.20  inches  (26.03  cm.),  the  entire  length  15.80 
inches  (40  cm.),  the  weight  is  3^  pounds  (1571  grams).  The  lanugo  on  the 
face  is  becoming  more  scanty,  but  the  hair  on  the  scalp  is  thicker.  One  testicle, 
generally  the  left,  has  descended  into  the  scrotum.  In  the  lower  epiphysis  of 
the  femur  ossification  begins.  The  nails  do  not  yet  project  beyond  the  finger- 
tips, although  they  are  firmer  in  consistency.  The  cord  is  relatively  a  little 
lower  in  its  insertion  than  it  was  the  previous  month. 

Vitality:  With  very  watchful  care  a  child  born  at  this  time  may  survive. 

End  of  the  Ninth  Month  or  Thirty-sixth  Week. — Characteristics:  The 
vertex-coccygeal  length  is  11. 10  inches  (27.94  cm.),  the  total  length  17.25  inches 
(44  cm.),  and  the  weight  is  5^  pounds  (2640  grams).  There  is  a  further 
increase  in  the  subcutaneous  fat.  The  development  of  the  nails  is  not  yet 
complete.  The  cranial  bones  are  compressible  and  very  susceptible  to  moulding. 
T'he  diameters  of  the  head  are  about  0.4  to  0.6  inch  (i  to  1.5  cm.)  less  than 
those  of  the  average  fetus  at  full  term  (Fig.  109). 

Vitality:  With  ordinary  care  the  fetus  almost  invariably  survives. 

End  of  the  Tenth  Month  or  Fortieth  Week. — Characteristics:  The  vertex- 
coccygeal  length  is  14.8  inches  (37  cm.),  the  total  length  19.84  inches  (50  cm.), 
and  the  weight  7  pounds  (3200  grams).  The  skin  is  pink,  but  paler,  more 
abundantly  supplied  with  fat,  and  has  less  lanugo.  The  nails  are  perfectly 
developed  and  project  beyond  the  finger-tips.  The  eyes  are  opened.  The 
ossification  center  in  the  lower  epiphysis  of  the  femur  is  0.2  inch  (5  mm.)  in 
diameter,  and  that  of  the  cuboid  bone  is  just  making  its  appearance.  The 
diameters  of  the  skull  are  normal  (Fig.  138).  (See  Physiologv  of  Labor,  Part 
IV.) 

Embryo,  Fetus,  and  Uterus  in  the  Several  Months  of  Gestation. — Although  it 
is  customary  to  measure  embryos  from  vertex  to  sole,  measurement  of  the  trunk 
(or,  in  youngest  embryos,  the  two  extreme  points)  is  doubtless  more  exact. 
During  the  first  and  second  months  only  the  trunk  can  be  measured,  and  in  the 
third  and  fourth  months  the  legs  cannot  readily  be  extended.  The  notable  dif- 
ferences of  various  authorities  may  be  explained  in  part  by  the  fact  that  em- 
bryos preserved  in  alcohol  diminish  in  weight  from  3  to  5  per  cent,  on  an  average 
(i  to  14  per  cent,  extremes)  according  to  the  strength  of  the  fluid;  and  in  part 
by  fluctuations  in  the  estimation  of  the  age.  Exact  data  upon  these  points 
are  entirely  wanting.  It  is  best  to  be  guided  in  judging  the  age  by  certain 
developmental  signs,  such  as  growth  of  lanugo  in  each  month,  etc.  In  the 
table  on  pages  86  and  87  the  vertex-coccygeal  lengths  of  the  embryo  and 
fetus  are  from  Schultze's  figures.*  The  weights  are  those  of  Droysen  and 
Gottengen  and  the  size  and  shape  of  the  uterus  are  the  author's  estimates. 
The  last  measurements,  it  must  be  remembered,  are  influenced  by  the 
presentation,  size,  and  number  of  the  fetus,  by  the  size  and  position  of  the 
placenta,  by  the  amount  of  liquor  amnii,  and  by  pathological  conditions. 

*  Schultze:  "  Gnindriss  der  Entwickltmgsgeschichte  des  Menschen  und  der  Sauge- 
thiere,"  Leipzig,  1897,  p.  137. 


CHANGES  IN  EXTERNAL  GENITALS,  VAGINA,  AND  CERVIX.     89 

II.  THE  PHENOMENA  PRODUCED  IN  THE  MATERNAL 
ORGANISM  BY  PREGNANCY. 

LOCAL    PHENOMENA    IN    THE    GENITAL    TRACT,    ADNEXA,    PELVIS, 

AND  BREASTS. 

1.  External  Genitals. — The  vulva  takes  part  in  the  general  hyperemia  of 
the  generative  system,  though  these  changes  are  rarely  apparent  until  the  third 
month.  The  labia  majora  and  minora  are  both  increased  in  size,  are  more 
elastic  and  resisting,  and  there  is  a  deeper  pigmentation  than  normal,  which 
is  particularly  marked  in  the  external  labia.  The  functional  activity  of  the 
sebaceous  follicles  and  sweat  glands  of  the  labia  is  increased,  and  the  external 
genitals  are  later  often  bathed  with  a  glairy  mucous  secretion.  Somewhat 
later  still  in  pregnancy  the  veins  and  venous  plexuses  are  much  engorged,  while 
distinct  varicosities  are  not  uncommon. 

2.  Vagina. — The  muscular  and  mucous  walls  of  the  vagina  are  thickened 
and  lengthened.  This  hypertrophy  is  particularly  well  marked  at  the  upper 
portion.  The  walls  are  consequently  strengthened,  so  as  better  to  accommodate 
the  passage  of  the  fetus  at  term.  The  mucous  membrane  becomes  darkened 
by  pigmentation.  The  attachment  of  the  mucous  coat  to  the  tissues  beneath 
becomes  loosened,  so  that  its  displacement  is  easy,  and  it  is  not  infrequently 
torn  off  in  labor,  thus  originating  vaginal  prolapse.  The  rugag  are  distinctly 
defined;  the  lymphatics,  as  well  as  the  blood-vessels,  are  unusually  developed; 
the  tissues  become  softened  and  infiltrated,  and  the  submucous  fat  decreases. 
On  account  of  the  increased  quantity  of  blood  in  the  loose  tissues,  as  well  as 
the  venous  stagnation  which  occurs,  the  vaginal  surface  looks  violet,  blue,  or 
purple,  instead  of  red  as  normally  (Fig.  7).  The  mucous  glands  produce 
an  abundant  secretion,  the  papillae  of  the  vagina  hypertrophy,  and  it  is  not 
uncommon  about  the  seventh  or  eighth  month  to  find  the  surface  covered 
throughout  its  whole  extent  with  myriads  of  these  little  pinhead  prominences, 
which  have  given  rise  to  the  term  "  granular  vaginitis  of  the  pregnant  woman." 
The  temperature  of  the  vagina  is  slightly  increased,  and  the  augmented  supply 
of  blood  to  the  part  causes  a  distinct  throbbing  of  the  vaginal  arteries,  readily 
detected  by  the  examining  finger,  the  so-called  "vaginal  pulse."  The  apparent 
length  of  the  vaginal  canal  varies  according  to  the  period  of  pregnancy  at  which 
the  examination  takes  place.  In  the  early  weeks,  before  the  uterus  rises  above 
the  pelvic  brim,  the  vagina  is  shortened;  afterward  it  increases  in  length  till 
the  middle  of  the  eighth  month  (as  a  result  of  the  sinking  of  the  uterus  at  this 
time),  when  it  again  becomes  shortened. 

3.  Cervix. — (i)  Consistency:  The  tissue  of  the  non-gravid  uterus  is  firm, 
hard,  and  non-elastic.  With  the  occurrence  of  conception,  softening  begins 
at  the  external  os,  and  gradually  extends  upward  till  the  whole  cervix  is  in- 
volved. It  is  caused  by  serous  infiltration,  with  which  passive  dilatation  of 
the  blood-vessels  is  associated.  At  the  end  of  the  fourth  month  the  lips  of  the 
OS  are  entirely  changed  in  consistence,  being  soft  and  velvety  on  palpation. 
By  the  sixth  month  one-half  of  the  cervix  has  participated  in  this  change,  and 
by  the  eighth  the  entire  cervix  is  involved. 

2.  Volume. — The  cervix  takes  part  in  the  hypertrophy  of  the  entire  uterus, 
its  volume  changing  somewhat  as  pregnancy  advances.  This  increase,  how- 
ever, does  not  compare  in  extent  with  that  of  the  body  of  the  uterus. 

3    Situation    and    Direction. — In  the  first  three    months  the  cervix  is 


90 


PHYSIOLOGICAL  PREGNANCY. 


lower  in  the  pelvis  and  a  trifle  to  the  left.  This  position  results  from  the  in- 
creased weight  and  the  pressure  upon  the  fundus  toward  the  right  by  the  dis- 
tended rectum.     After  the  third  month  the  cervix  rises  higher  in  the  pelvis 


MESO-SIGMOID 
UTERUS  \ 

RECTO-VAGINAL    POUCH 

RECTUM  \ 


LEFT    COMMON    ILIAC    V 

RIGHT    COMMON    ILIAC    A 

ROUND    LIGAMENT    OF    UTERUS 


UMBILICUS 


DEEP    EPIGASTRIC    A 
FALLOPIAN    TUBE 
OVARY 


UTERO    VESICAL    POUCH 
BLADDER 


RAPHE    OF    LEVATOR    ANi     M 

EXTERNAL    SPHINCTER    ANI    M 


DORSAL    VEIN    OF    CLITORIS 


VESICAL    PLEXUS    OF    VEINS 
\  URETHRA 


INTERNAL    SPHINCTER    ANI     M 

PERINEAL    BODY 


Fig. 


117- — Sagittal    Section    of    Normal   Adult   Pelvis. — {Deaver.) 


till  the  last  two  or  three  weeks  of  gestation,  when  it  sinks  again.  Sometimes 
toward  the  end  of  pregnancy,  if  the  head  is  the  presenting  part,  it  pushes  forward 
the  lower  anterior  wall  of  the  uterus,  causing  the  cervix  to  point  backward. 


CHANGES  IN  THE    UTERUS. 


91 


or  even  a  little  upward.*     The  cervix  changes  in  direction    according  to  the 
movements  of  the  uterine  body. 

4.  Cervical  Canal. — Coincident  with  the  cervical  softening,  the  cavity 
becomes  broader,  and  the  external  os  patulous.  The  time  of  this  change  varies 
according  as  the  patient  is  a  primigravida  or  a  multigravida.  Sometimes,  in 
the  former  case,  the  external  os  remains  closed  till  the  end  of  pregnancy;  but 
even  under  these  circumstances  it  generally  becomes  patulous  after  the  seventh 
month.  In  multigravidae  this  change  is  more  pronounced,  so  that  in  the  last 
months  of  gestation  it  is  often  possible  to  feel  the  membranes  through  the 


URETER    (behind    PERITONEUM) 
LOOP    OF    SMALL    INTESTINE 

VERMIFORM    APPENDIX 


CECUM    (displaced    UPWARd) 


DEEP    EPIGASTRIC    A 


FUNDUS    OF    UTERUS 

FIMBRIATED    EXTREMITY    OF    FALLOPIAN    TUBE 

SIGMOID    FLEXURE    (DISPLACED    UPWARD) 

LOOP    OF    SMALL   INTESTINE 


ROUND    LIGAMEMT 


ODLITCRATED    HYPOGASTRIC    A 
EXTERNAL   ILIAC  a(dEHIND  PERITONEUM) 


BLADDER    (olSTENDEo) 
FALLOPIAN    TUBES 
URACHUS 

Fig.    118. — Pelvic   Contents    seen    from    Above. — [Deaver.) 


APPENDICULO-OVARIAN     LIGAMENT 


patulous  OS.  The  alleged  shortening  of  the  cervix,  as  taught  by  old  authorities, 
has  been  shown  to  be  non-existent;  but  during  the  two  weeks  just  preceding 
labor  some  shortening  does  begin  to  take  place,  proceeding  from  above  down- 
ward till  the  cervical  canal  is  merged  into  the  uterine  cavity;  this  shortening 
is  owing  to  the  incipient  contractions  of  the  uterus  which  are  preparing  the 
cervix  for  labor. 

4.  Uterus. — The   most   important    changes   in   the   whole   organism   during 
pregnancy  take  place  in  the  uterus.     The  alterations  which  the  latter  undergoes 

*  Sacciform  dilatation  of  the  lower  uterine  segment. 


92 


PHYSIOLOGICAL  PREGNANCY. 


as  the  result  of  each  menstrual  period  must  be  regarded  as  an  introduction 
to  that  series  of  changes  which  end  only  with  the  return  of  the  organ  to  its 
normal  condition  after  the  expulsion  of  the  product  of  conception  (see  Men- 
struation, page  20). 

I.  Volume  and  Size. — The  volume  or  size  of  the  small,  inflexible  virgin 
uterus  is  expressed  by  2f  inches  (7  cm.)  in  length,  i|  inches  (4.5  cm.)  in  breadth, 


s.u.a.     t.s.a.     t.c 


t.s.p' 
h.a. 


u.s.l. 
o. 


u. 


t.s.p. 


U.S.L 


t.ur.a. 


■:'.i.»e^'^ 


v.p.c. 


ui. 


u.a. 
o.l. 


Fig.  119. — The  Pelvic  Inlet  and  Female  Pelvic  Organs  in  a  Woman  Forty  Years 
Old,  Who  has  borne  Children.  The  bladder  is  partially  filled  with  urine.  (J  natural 
size.)  i.s.a.,  Internal  spermatic  artery;  s.u.a.,  superior  ureteric  artery;  c.i.v.,  common 
iliac  vein;  i.s.p.,  internal  spermatic  plexus;  h.a.,  hypogastric  artery;  u.,  ureter;  u.s.l., 
utero-sacral  ligament;  0.,  o.,  ovary;  e.i.a.,  external  iliac  artery;  e.i.v.,  external  iliac  vein; 
r.l.,  round  ligament;  e.a.,  epigastric  artery;  f.t..  Fallopian  tube;  v.p.c,  vaginal  portion 
of  cervix;  i.e.,  inferior  cava;  a.,  aorta;  nt.s.a.,  median  sacral  artery;  c.i.v.,  common 
iliac  vein;  s.f.,  sigmoid  flexure;  u.,  ureter;  M.5.Z.,  .utero-sacral  ligament;  u.a.,  uterine 
artery;  o.l.,  ovarian  ligament;  ut.,  uterus;  b.,  bladder;  i.ur.a.,  inferior  ureteric 
artery. — (Tandler  and  Halban.) 


and  I  inch  (2.5  cm.)  in  thickness.  The  hypertrophy  of  the  uterus  is  concerned 
not  only  with  the  muscle-fibers,  but  with  the  connective  tissue  and  all  the 
vessels.  These  changes  are  reflex  in  character,  and  begin  with  impregnation. 
Indeed,  the  uterus  increases  up  to  the  fourth  month,  even  in  tubal  or  any  form 
of  extrauterine  pregnancy.  The  growth  of  the  ovum  may  act  at  first  as  a 
physiological  cause  of  these  changes,  but  not  as  a  mechanical  one.  Uterine 
enlargement  is  not  directly  dependent  upon  the  presence  of  the  ovum,  for  the 


SIZE  OF  THE  UTERUS. 


93 


latter  does  not  entirely  fill  the  cavity  of  the  organ  at  the  end  of  the  fifth  month; 
consequently  it  is  not  until  this  time  that  mechanical  distention  can  be  reckoned 
as   an  influential   factor.     At  first  this  hypertrophic   process   affects    all  parts 


Fallopian 
tube 


!Pfr~-' 


Round 
Ligament 


Body  of  Uterws 
. —  Isthmus'  -^_ 


Extroy  Vaaincd 
,  portion  on  Cervix, 

External  os 

Posterior  Wall  of 
Vo^inciy- 


Fig.    120. — The   A.vter[or    Surfaces   of  the   Nuli.iparols   axu   Multiparous   Uterus 

COiMPARED. 


"  EtLndiis 
'   FcdlopimiTiibe 

CaviiyofBody 


^,,---  Isthmus  -- -._ 

Internal  os 

.--- Cerncal  Canal 
j\fQch 


-  Lateral  Ti(/7inal 

CiLideSac. 
External  os 


ZateralTiiffinalWall 
PosteriorVa^malMilt 


Fig.    12  1. — Sagittal    Sections    of   the    Nulliparous    and    Multiparous    Uterus. 


of  the  organ  ahke,  but  later  the  cervix  grows  more  slowly  than  do  the  fundus 
and  the  body.  At  one  period  the  walls  attain  the  thickness  of  five-eighths  of  an 
inch  (1.5  cm.).     The  thickness,  however,  decreases  in  the  latter  part  of  gesta- 


94 


PHYSIOLOGICAL  PREGNANCY. 


tion,  on  account  of  extreme  distention,  to  three-sixteenths    of    an   inch  (0.5 
cm.).     The  capacity  of  the  "virgin  uterus,  which  is  almost  imaginary,  may  be 


Fig.   122. — Virgin  Cervix  and  Os  with 
Oval  Opening. 


Fig.   123. — Virgin  Cervix  and  Os   with 
Transverse  Fissure. 


Fig.    124. — Virgin  Cervix  and  Os  with  Oval  Opening. 


Fig.     12  i;. — Multiparous      Cervix      with 
Gaping  Fissured  Os. 


Fig.  126. — Cervix  and  Os  of  Ad- 
vanced Age  with  Small  Round 
Opening. 


increased  as  much  as  5 19-fold  at  term  (Krause,  Levret).     The   outer  surface 
of  the  virgin  uterus  measures  six  square  inches,  while  at  term  it  amounts  to 


SIZE  OF  THE  UTERUS. 


95 


339  square  inches.     The  unimpregnated  uterus  weighs  about  i\  ounces  (35.43 
gm.),  while  the  pregnant  organ  at  term  weighs  about  two  pounds  (900  gm.). 


Fig.  127. — Sagittal  Section  of  Uterus  and  Pelvic  Contents  at  the  Second  Month 
OF  Pregnancy.     Retroversion.      {\  natural  size.)  —  {Schaeffer.) 


Fig.  128. — Sagittal  Section  of  Uterus  and  Pelvic  Contents  at  the  Third  Month 
OF  Pregnancy.  Unusual  vertical  position  of  the  gravid  uterus.  (J  natural  size.) — 
(Schaeffer.) 


I/iff^r/tf//  o.s 


Fig.  129. — Frozen'  Section  of  a  Uterus  at  the  Third  Month.     Uterus  resting  normally 
on  the  bladder.      Placenta  and  membranes  in  the  uterus. — (Freimd.) 


Fig.  130. — Sagittal  Section  of  Uterus 
AND  Pelvic  Contents  at  the  Fourth 
Month  of  Pregnancy.  Primigravida. 
Breech  presentation.  Normal  position  of 
the  uterus.     (J  natural  size.)  —  (Schaeffer.) 


Fig.  131. — Frozen  Section  of  a  Uterus 
at  the  Fourth  Month  of  Pregnancy. 
Placenta  and   membranes  are   retained. 

— (Freund.) 


96 


Fig.   132. — Pregnant  Uterus  at  the  Fifth  Month,  showing  Anterior  Surface  and 
Prominent  Right  Horn   (Unicornate  Uterus). — (Author's  case.) 


Fig.  133. — Uterus  of  Fig.  132  Opened  Posteriorly,  showing  Unruptured  Amnion 
with  Contained  Fetus,  Thickness  of  the  Uterine  Walls,  and  Length  of  Uterine 
Canal. — {Author's  case.) 

7  97 


98 


PHYSIOLOGICAL  PREGNANCY. 


Fig.  134. — Amnion  and  Fetus  from  Fig.  133  after  Entire  Specimen  was  Hardened  in 
Formaldehyde.     Shows  posture  of  fetus  and  shape  of  the  fetal  ovoid. — (Author's  case.) 


Crest 


Ilium 


Internal  os.  ^''^*K^ 

V(/ffinaI fornix       ^ 
External  os. ^ 


'  '  i-{  '*"*^^^Ti? — Ischudluberosify 


^^^-  135. — Frozen  Transverse  Section  of  a  Uterus  from  a  Multigravida  at  the 
Thirty-sixth  Week.  No  uterine  contractions  have  occurred.  The  cervix  is  closed 
and  the  canal  unshortened.     Death  from  eclampsia.      {\  natural  size.) — {Leopold.) 


'       Irdernal  os 


Erigrmil  OS. 


Fig    136. — Frozen  Section  of  a  Uterus  at  the  Seventh  Month,  with  Retained 
Placenta   and  Membranes. — (Freund.) 


99 


100 


PHYSIOLOGICAL  PREGNANCY. 


For  the  size  of  the  uterus  at  the  end  of  each  calendar  month  see  table,  pages 
86  and  87. 

2.  Shape. — The  virgin  uterus  is  pyriform  or  pear-shaped,  flattened  from 
before  backward  (Fig.  120).  Its  upper  end  or  fundus,  the  broad  extremity  of 
the  organ,  is  directed  upward  and  forward  (Fig.  119).  Its  lower  end,  or  apex, 
looks  downward  and  backward.  Consequently  it  forms  an  angle  with  the 
vagina.     During  the  first  six  or  eight  weeks  of  gestation  the   organ  loses  its 


«^^^ 


Fig.  137.— Pregnant  Uterus  at  Thirty-eighth  Week  seen  from  the  Front.  Ante- 
rior walls  are  held  back  to  show  the  maternal  surface  of  the  placenta,  the  tinruptured 
amnion,  thickness  of  the  uterine  walls,  and  the  length  of  the  cervical  canal. — {Author's 
case.) 


flattened  pear  shape  and  bulges  out  over  the  cervix,  in  all  the  transverse  diam- 
eters, but  more  particularly  antero-posteriorly ;  so  that  now  the  uterus  resembles 
very  much  an  old-fashioned  jug  inverted  (Fig.  169).  Later  it  expands  more 
in  the  lower  segment,  and  by  the  fifth  month  its  form  is  midway  between  spherical 
and  pyriform,  the  vertical  diameter  being  longest  (Fig.  132).  Its  antero- 
posterior measurement  is  greatest  just  below  the  middle  of  the  body.  During 
the  last  of  pregnancy  it  becomes  egg-shaped,  ovoid,  or  cylindrical  (Fig.  137). 
These  changes  in  shape  occur  in  the  normal  uterus,  but  may  be  influenced  by 


SHAPE  OF  THE  UTERUS. 


101 


multiple  pregnancies,  by  anomalies  of  the  liquor  amnii,  and  by  pathological 
conditions.  Asymmetry  of  the  corpus  uteri  often  exists  even  at  a  very  early 
period  of  pregnancy  (Figs.  13.2,  139  to  143).  Fig.  132  of  the  author's  collection 
shows  this  condition.  The  bulging  portion  is  often  marked  bff  from  the  rest 
of  the  corpus  by  a  furrow  (Fig.  163)  (compare  Diagnosis  of  Pregnancy). 

The  shape  of  the  uterus  at  the  end  of  each  calendar  month  is  as  follows: 
End  of  first  month,  pyriform,  by  reason  of  marked  antero-posterior  growth, 
changing  to  cylindrical;  second  month,  exaggeration  of  first  month,  spherical 
form  suggested;  third  month,  almost  spherical;  fourth  month,  marked  ovoid 


Fig.  138. — Frozen  Section  of  Uterus  from  a  Primipara  at  the  Fortieth  Week. 
Uterine  contractions  have  just  commenced.  Death  from  eclampsia.  Note  the  un- 
shortened  cervical  canal  and  the  lateral  flexion  of  the  bodyyand  head  of  the  fetus. 
(J  natural  size.) — {Leopold.) 


with  round  anterior  and  flattened  posterior  surfaces;  fifth  month,  exaggeration 
of  fourth  month;  sixth  month,  ovoid  changing  to  egg-shape  with  posterior  wall 
flattened  by  spinal  column;  seventh  month,  egg-shaped,  broadest  just  below 
fundus;  eighth  month,  exaggeration  of  seventh  month,  lower  portion  widening 
out;  ninth  month  or  full  term,  ovoid  shape  with  predominance  of  longitudinal 
axis;  anterior  surface  more  convex,  with  marked  bulging  of  anterior  part  of 
lower  uterine  segment,  caused  by  fetal  head.  A  posterior  depression  caused 
by  the  lumbo-sacral  angle  and  fundus  may  be  due  to  irregular  posture  of  the 
fetus. 


102 


PHYSIOLOGICAL   PREGNANCY. 


3.  Situation  or  Position. — On  account  of  increased  weight,  the  uterus, 
in  the  early  months  of  pregnancy,  sinks  down  into  the  pelvic  cavity.  After 
the  third  month  it  rises  gradually,  till  it  almost  touches  the  diaphragm,  and 
before  term  it  sinks  again  by  reason  of  the  engagement  of  the  lower  part  of  the 
uterus  in  the  pelvic  cavity,  and  the  relaxation  of  soft  parts  preceding  delivery. 
This  is  called  the  "lightening"  before  labor.  The  virgin  uterus  is  normally 
anteflexed  (Fig.  117).  This  condition  becomes  much  accentuated  in  pregnancy, 
especially  when  the  abdominal  walls  are  lax,  as  after  the  patient  has  borne  a 
number  of  children,  when  anteflexion  is  much  exaggerated.     Not  only  does 


/■/      -"^'^ 


Fig. 


i3g. — Egg-shaped 
Uterus. 


Fig.     140. — Cylindrical- 
shaped  Uterus. 


Fig. 


141.- 


-Unicornate-shaped 
Uterus. 


\ 


Fig. 


142. — Bicornate-shaped 
Uterus  Arcuatus. 


Uterus, 


Fig.  143. — Oblique  Cylindrical-shaped 
Uterus  in  Shoulder  Presentation. 


the  sinking  of  the  organ  depend  upon  its  increase  in  weight,  but  also  on  the 
greater  surface  of  the  fundus  exposed  to  the  downward  pressure  of  the  intestines. 
Before  the  pregnant  uterus  has  risen  out  of  the  pelvis,  the  abdomen  is  not  in- 
creased in  size  In  fact,  it  is  often  said  to  be  flatter,  on  account  of  the  partial 
descent  of  the  uterus  into  the  pelvis.  About  the  middle  of  the  third  or  begin- 
ning of  the  fourth  month,  however,  the  fundus  slowly  rises  above  the  pelvic 
brim,  and  it  may  then  be  felt  as  a  smooth,  rounded  tumor. 

4.  Axis. — While  the  uterus  is  in  the  pelvic  cavity  its  longitudinal  axis  changes 
from  time  to  time,  like  that  of  the  nonpregnant  organ.     These  alterations  in 


MUSCULAR   TISSUE  OF   THE    UTERUS. 


103 


direction  probably  depend  on  the  condition  of  the  bladder.  Later  on  in  preg- 
nancy, when  the  uterus  has  extended  up  into  the  abdomen,  it  tends  to  tilt  for- 
ward against  the  abdominal  wall,  and  its  axis  corresponds  more  nearly  with  that 
of  the  pelvic  brim,  the  angle  formed  with  the  horizon  being  30  degrees.  At  term, 
the  position  and  relations  of  the  uterus  vary  with  the  posture  of  the  woman. 
While  upright,  the  heavy  fundus  inclines  forward  against  the  abdominal  parietes, 
as  far  as  the  consistency  of  the  latter  will  permit.  In  the  recumbent  position, 
the  uterus  rests  against  the  spinal  column  in  the  lumbar  region,  while  the  fundus 
approaches  the  diaphragm.,  and  the  intestines  are  massed  around  the  organ  in 
front  and  at  the  sides,  particularly 
the  left  side  (Fig.  160).  In  either 
lateral  position  the  uterus  natur- 
ally inclines  to  the  corresponding 
side.  In  women  with  very  lax  ab- 
dominal parietes  the  fundus  may 
even  hang  downward,  there  not 
being  sufficient  support  from  the 
flaccid  muscles  of  the  abdomen 
(Fig.  151).  Besides  the  anterior 
obliquity,  there  is  also  a  right 
lateral  obliquity,  to  explain  which 
many  theories  have  been  ad- 
vanced (Fig.  160).  Rotation 
(torsion)  on  its  longitudinal  axis 
is  often  noticed,  so  that  the 
ovaries  are  displaced,  the  left  gen- 
erally lying  toward  the  middle 
line  and  forward,  while  the  right 
is  directed  backward  (Fig.  i6o). 
The  cervix  naturally  follows  in 
the  wake  of  the  larger  body.  In 
extreme  anteflexion  it  cannot 
always  be  felt. 

5.  Consistency.  —  The  con- 
sistency of  the  pregnant  uterus 
changes  from  the  rigid,  firm,  in- 
elastic condition  of  the  non-preg- 
nant organ  to  the  soft,  elastic 
consistency  which  increases  with 
the  advance  of  pregnancy  An 
obscure  sense  of  fluctuation  is 
often  perceived.  This  consistency 
differs  from  that  of  metritis,  which 

causes  a  hard  and  non-elastic  uterus;  from  that  of  subinvolution,  which  gives 
a  soft  but  inelastic  consistency  to  the  organ;  and  from  that  of  fibroid,  which  is 
also  hard  and  inelastic.  So,  at  term,  the  full-grown  fetus  is  contained  within 
a  flexible-walled  cavity. 

6.  Mucous  Membrane. — (See  Decidua,  page  45.) 

7.  Muscular  Layers. — In  the  non-pregnant  uterus  the  muscle-fibers  have 
a  very  irregular  distribution.  Roebger  has  done  very  important  work  on  this 
subject,  and  says  that  we  do  not  find  definite  layers  of  muscles.  Much  dis- 
cussion has  taken  place  as  to  the  musculature  of  the  pregnant  uterus.     Luschka 


Fig.  144. — Height  of  the  Fundus  and  Posi- 
tion OF  THE  Cervix  in  the  Several  Weeks 
OF  Gestation. 


104 


PHYSIOLOGICAL  PREGNANCY. 


and  Henle's  work  is  as  good,  as  any.  They  believe  the  pregnant  uterus  to  con- 
sist of  three  layers:  (i)  An  external  or  hood-like,  longitudinal  layer,  passing 
over  from  the  fundus  of  the  uterus  and  continuing  into  the  ligaments  (Fig.  152). 
(2)  A  median  layer,  where  the  network  of  fibers  attains  its  greatest  thickness 
(Fig.  154).  (3)  An  internal  layer,  which  forms  the  sphincters  about  the  uterine 
orifices — tubes  and  os  uteri  (Fig.  153).  These  chief  layers  are  connected  by 
communicating  groups,  so  that  when  they  are  separated  the  intervening  spaces 
are   rhomboidal   in   shape.     The   connective  tissue  between  the   muscle-fibers 


ife-, 


IZ'^-WEEK 


20™WEEK 


32""  WEEK 


40"WEEK 


Fig.  146. 


Fig.  147. 


-Shape    of    the  Abdomen  in  a  Primigravida.- 
photographs.) 


Fig.  148. 
-{Redrawn    from.   Hirst's 


soon  becomes  increased,  and  toward  the  last  of  pregnancy  exhibits  distinct 
ftbrillas  (Ruge,  Hofmeier).  By  hypertrophy  and  hyperplasia  the  three  muscular 
layers  are  defined.  The  hypertrophy  of  the  single  muscle-fibers  is  perhaps 
the  most  striking  change  in  the  whole  organism,  the  increase  being  eleven  times 
in  length  and  five  times  in  width.  The  new  muscular  elements  rapidly  grow 
as  well. 

8.  Fibrous  Tissue. — The  fibrous  tissue  is  increased,  chiefly  by  absorption 
of  fluid  and  consequent  increase  in  bulk,  and  it  sends  in  its  newly  developed 


Fig.   149. — Shape  of  the  Abdomen   in  a  Young  Primigravida  at  Full  Term  after 
THE  Falling  of  the  Uterus  and  in  the  Dorsal  Posture. 


Fig.    150. — Shape  of  the   Abdomen   in   a   Young   Prumigravida  at  Full  Term   after 
THE  Falling  of  the  Uterus  and  in  the  Standing  Posture. 

105 


106 


PHYSIOLOGICAL  PREGNANCY. 


fibers  between  the  muscle  bundles,  thus  adding  its  influence  to  the  other  factors 
which  change  the  consistency  of  the  uterus  in  the  gravid  state. 

9.  Arteries  and  Veins. — The  arteries  increase  in  calibre  and  length.  Their 
tortuosity  is  not  lost.  The  veins  enlarge  into  wide  channels,  the  sinus  uteri. 
These  penetrate  between  the  muscle  bundles  and  are  especially  well  developed 
at  the  placental  site.     The  walls  of  these  channels  do  not  collapse  when  injured, 


Fig.  151. — Shape  of  the  Abdomen  in  a  Multigravida  with  a  Moderate  Generally 
Contracted  Pelvis  at  the  Thirty-eighth  Week  and  in  the  Standing  Posture. 


on  account  of  the  close  connection  between  them  and  the  surrounding  connective 
tissue.  They  are  obliterated  after  labor  by  the  contraction  of  the  uterine 
muscle,  which  surrounds  them.  These  blood-vessels  penetrate  the  minutest 
divisions  of  the  chorion  frondosum,  and  consist  of  the  end  ramifications  of  the 
umbilical  arteries  and  veins.  The  arteries  and  veins  pursue  their  course  side 
by  side,  a  distinguishing  characteristic  of  the  latter  being  their  thin  walls  and 


ARTERIES   AND    VEINS  OF   THE    UTERUS. 


107 


large  calibre.  Only  capillaries  occupy  the  terminal  villi.  They  are,  as  a  rule, 
just  under  the  epithelium,  and  are  connected  by  free  anastomoses.  They  are 
so  abundant  that  this   area  has   the  appearance  of  a  saturated  sponge.     Their 


Fig.  152. — External  Muscular  Layer  of 
THE  Pregnant  Uterus.  Anterior  Sur- 
face. I,  Fallopian  tube.  2,  Round  liga- 
ment. 3,  Ovarian  ligament.  4,  Trans- 
verse fibers.  5,  Longitudinal  fibers.  6, 
Z-shaped  arrangement  of  fibers.  7,  Orifice 
of  external  os. — (Henle.) 


Fig.  153. — Internal  Muscular  Layer 
OF  the  Pregnant  Uterus  after 
Removal  of  the  Two  Outer  Layers. 
I,  Section  of  the  external  layer.  2, 
Section  of  the  middle  layer.  3,  Fal- 
lopian tubes.  4,  Circular  fibers  of 
the  horns.  5,  Circular  fibers  of  the 
isthmus.  6,  Circular  fibers  of  the 
cervix.  7,  Orifice  of  the  external  os. 
—  (Henle.) 


diameter  is  large  enough  to  accommodate  five  or  six  red  corpuscles  side  by  side. 
They  have  a  delicate  endothelial  wall,  which,  together  with  the  chorionic  epi- 


FiG.  154. — Middle  Muscular  Layer  of  the  Pregnant  Uterus,  i,  Left  tube.  2,  Right 
tube.  3,  Fundus  uteri.  4,  Superficial  muscular  layer  incised  and  turned  back.  -  5. 
Flexiform  fasciculse  of  the  middle  layer.  6,  EUiptical  openings  occupied  by  the  uterine 
sinuses. — (Henle.) 


thelium,  alone  separates  the  fetal  from  the  maternal  blood  in  the  intervillous 
spaces.  The  uterine  artery  is  much  enlarged  during  pregnancy,  but  relatively 
less  so  than  the  ovarian.     As  pregnancy  advances  it  becomes  more  tortuous 


108  PHYSIOLOGICAL   PREGNANCY. 

its  course  being  less  direct,  and  its  attachment  to  the  uterine  wall  loosened.* 
Its  level  in  the  pelvis  will  depend  on  the  upward  growth  of  the  uterus,  as  well 
as  on  its  attachment  to  the  pelvic  wall,  and  its  relation  to  the  outer  border  of  the 
broad  ligament  is  lost  in  the  latter  part  of  pregnancy.  Its  relation  to  the  ureter 
is  the  same  in  pregnant  and  non-pregnant  uteri  (Fig.  156).  The  ovarian  artery 
is  greatly  enlarged  in  pregnancy.  Its  course  from  the  point  where  it  reaches 
the  pelvic  brim  at  the  bifurcation  of  the  common  iliac  artery  is  upward  and 
forward,    accompanying   the   infundibulo-pelvic   hgament,    lying   close   to   the 


I  s.  and  i.g. 

^^  \spe.p. 


Fig.  155. — Nerve-Supply  of  the  Female  Genital  Organs,  p-n..  Phrenic  nerve;  s.n., 
splanchnic  nerve;  l.g-s.,  lumbar  ganglion  of  the  sympathetic;  g.u.p.,  great  uterine 
plexus;  r.p.h.,  right  hypogastric  plexus;  s.p.,  sacral  plexus;  r.c.g.,  right  cervical  gan- 
glion; 7;.M.,  vagus  nerve;  s.n.,  splanchnic  nerve;  5.g.,  solar  ganglion;  5.r.g.,  suprarenal 
ganglion;  'i.r.g.,  infrarenal  ganglion;  s.  and  i.g.,  superior  and  inferior  genital  ganglia; 
spe.p.,  spermatic  plexus  (ovarian  nerves). — (Frankenhduser.) 

ovary,  overshadowing  the  Fallopian  tubes,  and  finally  reaching  the  comu  of 
the  uterus  (Polk)  (Figs.  156  and  157). 

10.  Nerves. — The  logical  view  seems  to  be  that  these  organs  of  sensation 
participate  in  the  general  increase  of  the  other  parts  of  the  uterus. 

11.  Lymphatics. — The  lymphatics  increase  greatly,  both  by  hypertrophy 
and  hyperplasia.  The  lymph  spaces  just  below  the  mucous  membrane  are 
much  increased  in  size,  and  the  lymph  channels  which  run  from  them  through 
the  muscles  of  the  uterus  reach  the  size  of  a  goose-quill.  Underneath  the  peri- 
toneum these  lymph  vessels  form  a  plexus  continuous  with  the  general  lymphatic 
system.     On  this  arrangement  of  these  absorbent  vessels  depends  that  striking 

*  Tandler  und  Halban:  "Topographie  d.  weibl.  Uterus,"  1901. 


PERITONEUM. 


109 


characteristic  of  the  uterus  after  labor,  its  readiness  to  take  up  and  assimilate 
infecting  material,  peritonitis  frequently  presenting  the  first  symptom  of  this 
process. 

12.  Peritoneum. — The  connective  tissue  found  in  the  uterus  between  its 
peritoneal  covering  and  the  muscular  walls  becomes  less  dense  and  more  cellular, 
so  that  while  the  peritoneum  in  the  non-gravid  state  was  closely  bound  to  the 
organ,  allowing  very  little  if  any  motion  between  the  two,  in  the  pregnant 
condition,  especially  at  term,  it  is  freely  movable  on  the  muscular  coat,  thus 
diminishing  the  risk  of  laceration  during  labor.     The  peritoneum  at  the  end 


c  t. 


ut. 


•\  ut. 
p.b.w. 


Fig.  156. — Relations  of  the  Ureters,  Uterine  Arteries,  and  Cervix  in  the  Non- 
pregnant State,  u.,  u.,  Ureter;  h.a.,  hypogastric  artery;  s.L,  suspensory  ligament; 
e.i.a.,  external  iliac  artery;  u.a.,  uterine  artery;  p.b.w.,  posterior  bladder  wall;  r.,  retro- 
uterine fold;  c,  cervical  canal;  u.a.,  uterine  artery;  c.t.,  cellular  tissue;  ut.,  uterus. 
— (Tandler  and  Halban.) 


of  pregnancy,  before  the  sinking  of  the  uterus,  shows  a  shallowing  of  the  anterior 
fossa,  and  the  pouch  of  Douglas  is  almost  obliterated.  The  retro-ovarian 
shelves  are  now  on  a  level  with  the  pelvic  brim,  instead  of  on  a  level  with  a  line 
drawn  from  the  middle  of  the  symphysis  to  the  third  or  fourth  piece  of  the  sacrum. 
The  pouch  of  Douglas  is  raised.  There  is  backward  displacement  of  the  broad 
ligaments,  from  the  growth  of  the  uterus,  causing  the  almost  complete  oblitera- 
tion of  the  posterior  fossa,  (a)  Broad  ligaments:  During  pregnancy  the  broad 
ligaments  are  drawn  upward,  so  that  at  full  term  the  bases  of  the  ligaments  lie 
on  a  level  with  the  pelvic  brim,  and  extend  from  the  pectineal  eminence  ante- 


no 


PHYSIOLOGICAL  PREGNANCY. 


riorly,  to  the  synchondrosis  posteriorly,  these  Umits  being  determined  by  the 
round  Hgaments  anteriorly  and  the  ovarian  artery  posteriorly.  Separation  of  the 
laminae  of  the  broad  ligaments  during  pregnancy  causes  the  triangular  form  at 


C.1.V 


u.Ll. 


p.c.l 


Fig.  157. — Topography  of  the  Uterine  Artery  and  Ureters  in  Pregnancy  at  Thirty- 
sixth  Week,  p..  Placenta;  c.i.a.,  common  iliac  artery;  c.i.v.,  common  iliac  vein; 
u.,  ureter;  d.p.,  Douglas'  pouch;  ii./.,  vaginal  fornix;  ^.c.Z.,  posterior  cervical  lip;  i.o.,  in- 
ternal os;  e.o.,  external  os;  r.,  rectum;  a.l.,  anterior  lip;  v.,  vagina;  i.v.,  internal  iliac 
vein;  u.l.l.,  umbilical  lateral  ligament;  u.a.,  uterine  artery;  b.,  bladder;  ur.,  urethra. — 
(Tandler  and  Halban.) 


full  term,  the  base  of  the  triangle  corresponding  to  the  pectineal  line,  and  its 
apex  to  the  horn  of  the  uterus  (Fig.  159).  After  delivery  the  ligaments  slowly 
regain  their  position  in  the  pelvis.  Hence  the  ureters  have  no  fixed  relation 
to  the  broad  ligaments  in  the  latter  part  of  pregnancy,  because  the  ureters  do 


PROPERTIES  OF  THE   UTERUS. 


Ill 


not  undergo  the  same  displacement  during  gestation,  (b)  The  utero-sacral 
ligaments  are  attached,  in  the  latter  part  of  pregnancy,  to  the  first,  instead  of 
to  the  third  or  fourth,  sacral  vertebra,  (c)  The  round  ligaments  by  the  growth 
of  the  uterus  are  drawn  up.  above  the  pelvic  outlet. 

13.  Properties. — (a)  Sensibility:  The  sensibility  of  the  uterus  undergoes 
very  little  change.  The  cervix  in  the  non-pregnant  state  may  sometimes  even 
be  cauterized  without  much  discomfort  to  the  patient.     But  the  sensibility  varies 


=^ri\ 


Fig.  158. — Topography  of  the  Uterine  Artery  and  Ureters  in  Pregnancy  at  the 
Thirty-sixth  Week. — Same  as  Fig.  157  with  upper  portion  of  left  uterine  wall  and 
a  portion  of  the  peritoneum  removed,  d.p.,  Douglas'  pouch;  l.s.u.,  lower  segment  of 
uterus;  v.f.,  vaginal  fornix;  c.c,  cervical  canal;  v.,  vagina;  h.a.,  hypogastric  artery;  ur., 
ureter;  i.s.a.,  internal  spermatic  artery;  i.s.p.,  internal  spermatic  plexus;  e.i.a.,  exter- 
nal iliac  artery;  u.a.,  uterine  artery;  e.i.v.,  external  iliac  vein;  u.l.l.,  umbilical  lateral 
ligament;  v.h.a.,  vesical  branch  of  uterine  arterv;  b.,  bladder;  u.,  urethra. — {Tandler 
and  Halban.) 


in  accordance  with  its  cause;  e.  g.,  forced  dilatation  of  the  cervix  is  quite  painful. 
The  body,  although  somewhat  less  sensitive  than  the  cervix,  is  not  entirely  insen- 
sible, for  pain  is  caused  by  the  contractions  of  labor,  or  by  the  introduction  of  a 
sound  or  hand.  Even  fetal  movements  are  painful  to  some  women,  {b)  Irrita- 
bility: This  property  also  differs  in  various  subjects.  Irritability  of  the  uterus, 
when  excessive,  is  probably  of  pathological  origin  The  slightest  cause  in  some 
women — a  misstep,  for  example — may  cause  abortion;  while  others  may  ride  to 
hounds  with  no  injurious  results,     [c)    Contractility:  The  muscle-fibers  exhibit 


112 


PHYSIOLOGICAL   PREGNANCY. 


contractility,  which  consists  in  a  shortening  of  the  fibers  followed  by  relaxation. 
Contractions  occur  throughout  pregnancy,  and  are  usually  painless;  they  promote 
the  uterine  circulation  and  help  to  fix  the  position  of  the  child. 

14.  Thickness  of  the  Walls. — The  great  increase  in  the  size  of  the  uterine 
cavity  is  not  due  to  the  mechanical  pressure  of  the  growing  ovum,  but  to  the 
hypertrophy  of  the  walls  themselves.  If  the  former  cause  obtained,  the  pregnant 
uterine  walls  would  be  much  thinner  than  those  in  the  non-gravid  state.  In  the 
first  three  months  the  walls  increase  a  little  in  thickness,  owing  to  the  rapid 
development  of  the  muscular  and  vascular  systems;  at  the  fifth  month  they 
are  about  normal  in  thickness  (Fig.  133),  and  at  term  they  are  of  a  thickness 
about  equal  to  that  of  the  non-pregnant  parietes,  although  a  trifle  thicker  at  the 
placental  site;  and  much  thinner  in  the  lower  uterine  segment,  the  thickness  thus 

varying     at     different     points 
(Fig.  137)- 

15.  Topographical  Rela- 
tions AT  Term  (Fig.  160). — 
The  topographical  relations  of 
the  intestines  are  worthy  of 
note.  They  are  always  above, 
behind,  and  at  the  sides  of  the 
uterus,  thus  giving  no  reson- 
ance over  the  anterior  abdom- 
inal wall.  In  front  of  the  uter- 
us are  the  vagina,  the  posterior 
surface  of  the  bladder,  and  the 
internal  surface  of  the  anterior 
abdominal  wall.  Now  and 
then,  as  an  exception  to  the 
statement  previously  made, 
one  or  more  coils  of  intestine 
intervene  between  the  uterus 
and  the  abdominal  wall.  Be- 
hind, the  uterus  is  in  relation 
with  the  rectum,  the  sacro- 
vertebral  articulation,  the  ver- 
tebral column,  the  mesentery, 
and  a  mass  of  intestines ;  on  the 
right,  with  the  corresponding 
side  of  the  pelvic  excavation,  the  iliac  vessels,  the  psoas  muscle,  caecum,  and  right 
abdominal  wall;  on  the  left,  with  the  corresponding  part  of  the  pelvis,  the  iliac 
vessels,  the  aorta,  the  sigmoid  flexure,  the  psoas  muscle,  and  a  mass  of  intestines 
which  separate  the  uterus  from  the  left  lateral  abdominal  wall.  The  fundus  is 
in  relation  with  the  transverse  colon,  a  part  of  the  stomach,  the  anterior  margin 
of  the  liver,  the  ensiform  cartilage  for  a  time,  and  the  lower  floating  ribs.  The 
ovaries  and  Fallopian  tubes  are  close  to  the  sides  of  the  uterus,  at  a  point  cor- 
responding to  the  junction  of  the  upper  and  middle  segments.  When  pregnancy 
is  drawing  to  a  close,  a  large  part  of  the  anterior  uterine  surface  is  in  contact 
with  the  abdominal  wall,  while  its  lower  surface  rests  against  the  posterior  part 
of  the  symphysis  pubis.  The  posterior  surface  leans  against  the  spinal  column; 
the  large  intestines  cover  the  fundus,  while  the  small  intestines  are  forced  to 
both  sides. 

5,  Bladder, — In  early  pregnancy  the  bladder  is  not  so  capable  of  expanding 


Fig.  159. — Broad  Ligaments  of  the  Pregnant 
State.  Pregnant  uterus  at  the  thirty-sixth  week. 
—{Polk.) 


BLADDER. 


113 


in  an  antero-posterior  direction,  and  so  the  distention  takes  place  laterally. 
In  the  displacements  of  the  uterus,  which  are  so  frequently  seen  in  preg- 
nancy, the  bladder  follows  the  uterus.      As  the   uterus   a^icends  in  its  growth, 


Fig.  i6o. — Topography  of  the  Uterus  at  the  Fortieth  Week.     Right  lateral  obliquity 
and  axial  torsion  from  left  to  right  of  the  uterus  are  present. —  (From  nature.) 


therefore,  the  urethra  elongates,  and  in  certain  uterine  displacements  may 
become  partially  or  completely  occluded,  thus  leading  to  overdistention  of  the 
bladder,  paralysis  of  its  musculature,  decomposition  of  the  retained  urine,  and 


114  PHYSIOLOGICAL  PREGNANCY. 

cystitis.  If  the  uterine  displacement  is  not  corrected,  there  may  result  dis- 
astrous vesical  troubles,  the  lining  membrane  may  be  cast  off  in  shreds,  or  a 
cast  may  be  thrown  off;  even  the  muscle-layer  may  contribute  to  the  general 
disturbance.  As  the  bladder  accompanies  the  uterus  in  its  upward  growth, 
the  orifice  or  bulb  of  the  urethra  is  elevated  and  hidden  behind  the  symphysis 
pubis,  and  it  is  consequently  more  difficult  to  introduce  a  catheter.  The  canal 
also  becomes  more  curved,  so  that  a  curved  male  catheter  is  used  with  more 
facility  than  the  straight  female  instrument.  The  dragging  upon  the  bladder 
by  the  initial  prolapse  of  the  uterus,  together  with  the  subsequent  (third  month) 
pressure  of  the  latter  when  anteverted,  diminish  the  size  of  the  bladder,  causing 
frequency  of  micturition.  At  times,  when  the  bladder  is  full,  a  simple  sneeze 
or  cough  will  cause  involuntary  discharge  of  urine.  Vesical  tenesmus  may 
also  annoy  the  patient,  particularly  during  the  first  three  months,  before  the 
uterus  rises;  and  also  during  the  last  fortnight  of  pregnancy,  after  it  has  fallen. 

6.  Ureters. — In  the  latter  part  of  pregnancy  the  ureters  do  not,  as  in  the 
non-pregnant  state,  follow  the  pelvic  wall  to  the  ischial  spines;  but,  having 
crossed  the  brim  near  the  bifurcation  of  the  common  iliac  artery,  they  accom- 
pany the  internal  iliac  artery.  They  leave  the  pelvic  wall  about  on  a  level  with 
the  brim,  pass  beneath  the  broad  ligament  on  the  same  level,  and  downward, 
forward,  and  somewhat  inward,  about  midway  between  the  pelvic  wall  and 
the  utero-vaginal  junction ;  and  approach  closely  the  anterior  wall  of  the  vagina, 
entering  the  base  of  the  bladder  about  one  inch  below  the  cervix,  and  about 
two  inches  below  the  spine  of  the  pubis  (Polk)  (Tandler  and  Halban)  (Figs 
156,  157,  and  158). 

7.  Rectum. — The  rectum  is  apt  to  be  loaded  during  pregnancy.  This 
constipation  is  not  so  much  due  to  the  local  uterine  pressure,  as  to  diminished 
peristalsis  of  the  intestinal  tract.  During  the  early  part  and  the  last  two  weeks 
of  gestation,  constipation  may  alternate  with  diarrhea,  from  the  irritation  caused 
by  the  descent  of  the  uterus.  From  interference  with  the  blood-supply,  hemor- 
rhoids may  develop  in  the  anus  and  rectum. 

8.  Lower  Extremities. — In  the  later  months  of  pregnancy,  oedema  and  vari- 
cose venous  enlargements  are  often  found,  due  to  the  obstruction  to  the  return 
circulation  (Part  III).  Numbness,  neuralgia,  pains,  cramps,  and  difficulty 
in  walking  may  all  result  from  the  pressure  of  the  uterus  upon  the  sacral  plexus. 

9.  Pelvic  Joints. — The  inter-articular  cartilages,  especially  that  of  the  sym- 
physis, become  softened  and  hyperemic,  and  more  movable.  The  pelvic  liga- 
ments also  participate  in  the  swelling  and  softening,  and  the  synovial  mem- 
branes are  increased  in  size  and  said  to  be  distended  with  fluid.  Thus  the  com- 
ponent parts  of  the  joints  are  pushed  apart.  Occasionally  a  case  is  so  extreme 
that  it  is  some  time  before  the  normal  power  of  walking  returns.  The  move- 
ment of  the  coccyx  on  the  sacrum  is  important.  This  permits  a  bending  back 
of  the  coccyx  during  labor,  thus  lending  an  efficient  aid  to  the  process,  for  the 
antero-posterior  diameter  of  the  pelvic  outlet  is  materially  increased  (see  Physio- 
logical Labor). 

10.  Breasts, — Intimate  sympathetic  relations  exist  at  all  times  between  the 
breasts  and  the  pelvic  organs.  Very  early  in  pregnancy,  usually  about  the 
second  month,  the  mammae  increase  in  size  and  become  tender.  This  growth 
continues  during  pregnancy,  and  consists  in  the  increase  of  connective  and 
glandular  tissues  and  fat.  Blue  veins  become  prominent  and  course  over  the 
breasts.  Permanent  strics  appear  at  any  time  after  the  sixth  month,  due  to 
stretching  of  the  cutis  vera,  which  permits  the  subcutaneous  fibrous  tissue  to 
glisten  through  (Fig.  161).     The   nipples   also   enlarge   and   become   sensitive. 


GENERAL  PHENOMENA.  115 

Their  power  of  erectility  is  also  increased.  They  are  often  covered  with  small 
branny  scales.  The  areolce  become  much  enlarged,  and  darker  in  color  from 
a  deposit  of  pigment.  This  varies  in  degree  with  the  complexion  of  the  patient. 
In  blondes  it  is  sometimes  scarcely  perceptible,  while  in  brunettes  a  great  part 
of  the  breast  may  be  involved.  The  areola,  in  addition  to  becoming  dark,  grows 
moist  and  swollen,  while  the  series  of  tubercles  increase  in  size  in  it  around  the" 
nipple.  Montgomery  believes  them  to  be  closely  connected  with  the  lactiferous 
ducts,  which  can  sometimes  be  traced  to  their  summits  where  they  open.  These 
also  increase  in  size  and  number  with  the  progress  of  pregnancy.  Outside  the 
primary  areola,  in  the  later  months  of  pregnancy,  a  secondary  circle  appears, 
called  the  secondary  areola.  This  is  composed  of  light  spots  scattered  all 
around  the  periphery  of  the  areola,  which  has  shaded  off  from  the  deeper  tones 
near  the  center.  This  change,  too,  is  more  marked  in  brunettes.  Even  as 
early  as  the  third  month,  pressure  on  the  breasts  may  force  out  a  drop  of 
serous-looking  liquid.  On  microscopic  examination  milk  and  colostrum  glob- 
ules will  be  detected,  the  latter  being  desquamated  epithelial  cells  of  the  glands 
filled  with  oil-globules  (Fig.  6). 

GENERAL    PHENOMENA. 

1.  Digestive  System. — Nausea  and  vomiting  are  common  disturbances  in 
pregnancy.  They  are  of  all  grades,  from  one  simple  attack  at  the  time  the 
woman  first  raises  her  head  from  the  pillow,  to  repeated  and  severe  vomiting 
spells,  which  occur  from  time  to  time  during  the  day,  and  even  in  the  night. 
These  attacks  sometimes  begin  with  conception;  more  commonly,  however, 
about  the  sixth  week,  lasting,  as  a  rule,  until  the  fourth  month.  The  assump- 
tion of  the  erect  position  seems  to  cause  this  nausea,  probably  on  account  of  the 
extra  congestion  brought  on  in  the  uterus  by  this  position,  thus  increasing 
its  irritability.  These  symptoms  may  result  from  various  conditions  of  the 
stomach  or  uterus,  though  the  common  and  probably  correct  explanation 
of  the  milder  variety  is  that  the  uterine  fibers  are  stretched,  and  the 
nerves  consequently  irritated.  (See  Toxemia  of  Pregnancy.)  Gastric  in- 
digestion may  also  occur,  causing  acidity,  flatulence,  heartburn,  eructations, 
etc.  The  intestines  seem  to  lack  their  normal  peristaltic  power,  and  that, 
together  with  the  pressure  of  the  growing  uterus,  renders  constipation  a 
common  ailment  of  pregnancy,  and  one  which  should  be  relieved  in  order  to 
prevent  overburdening  the  kidneys.  Diarrhea  and  excessive  flatulence  are 
at  times  not  uncommon.  The  former  may  be  of  nervous  origin,  due  to  the 
mechanical  irritation  of  the  intestines  by  the  growing  uterus.  Intestinal  in- 
digestion is  also  very  common,  and  may  give  rise  to  severe  cramps.  The  ap- 
petite is  apt  to  be  capricious  in  early  pregnancy,  though  it  may  change  and 
become  ravenous.  There  may  be  curious  morbid  cravings  for  various  sub- 
stances, such  as  clay,  chalk,  slate-pencils,  certain  vegetable  acids,  etc.;  even  dis- 
gusting articles  may  come  into  the  category. 

2.  Heart. — The  existence  of  hypertrophy  of  the  left  ventricle  has  usually 
been  taught  as  a  physiological  change  in  pregnancy  to  meet  the  extra  demands 
made  on  the  organism  by  the  complex  vascular  arrangement  of  the  pregnant 
uterus.  The  right  ventricle  and  the  two  auricles  were  not  believed  to  participate 
in  this  hypertrophy.  Alfred  Stengel  and  W.  B.  Stanton,  of  Philadelphia,  how- 
ever, controvert  the  old  French  notion  that  the  heart  becomes  hypertrophied 
during  pregnancy.  By  a  series  of  carefully  made  tracings  and  readings  of  instni- 
ments^devised  for  the  measurement  of  blood-pressure,  they  show  the  correctness 


116  PHYSIOLOGICAL  PREGNANCY. 

of  Gerhardt's  idea  that  the  growth  of  the  fetus,  by  pressing  up  the  diaphragm, 
forces  the  apex  of  the  heart  upward  and  outward,  and  that  this  dislocation 
has  been  misinterpreted  as  a  sign  of  hypertrophy.  The  tracings  in  twenty- 
six  cases  with  careful  measurements  show  this  dislocation,  which  disappears 
after  parturition.  There  is,  however,  a  shght  irregularity  in  the  contour  of 
the  upper  right  margin  of  the  heart,  indicative  of  a  slight  hypertrophy  of  the 
right  conus  arteriosus.  The  murmurs  which  are  heard  in  primigravidse  are 
probably  the  result  of  a  slight  overaction  of  the  right  heart.  No  constant 
changes  in  blood-pressure  could  be  demonstrated. 

3.  Lungs. — The  mother  has  to  provide  for  the  nourishment  of  her  child 
and  herself  during  pregnancy,  therefore  an  extra  quantity  of  blood  must  not 
only  be  circulated  but  purified.  In  this  process  the  elimination  of  carbonic 
acid  gas  must  be  increased.  By  mechanical  pressure  of  the  growing  uterus 
the  diaphragm  is  forced  upward,  lessening  the  longitudinal  diameter  of  the 
respiratory  space,  although  the  lower  thorax  is  somewhat  broadened.  This 
decrease  in  breathing  space  causes  a  certain  amount  of  dyspnea,  from  the  time 
of  the  beginning  till  the  last  weeks  of  pregnancy,  when  the  uterus  sinks  again, 
and  respiration  and  circulation  are  carried  on  with  greater  ease.  In  the  early 
months  cough  and  dyspnea,  from  sympathy,  may  cause  a  derangement  of  the 
respiratory  organs,  while  the  same  is  later  caused  by  the  growing  uterus.  These 
phenomena  are  most  common  in  twin  pregnancies,  or  in  dropsy  of  the  amnion. 

4.  Liver. — Tiny  fatty  globules  occur  in  the  cells  of  this  organ,  varying  in 
size  from  a  pin's  head  to  a  millet-seed.  De  Sinety  believes  this  change  to  be 
particularly  associated  with  lactation,  and  to  disappear  after  that  period.  The 
liver  is  also  enlarged,  as  are  the  spleen  and  lymphatic  glands,  both  the  latter 
showing  the  same  fatty  changes.  The  enlargement  of  the  spleen  is  due  to  the 
important  relation  existing  between  it  and  the  quantitative  change  in  the 
circulating  blood.     (See  Toxemia  of  Pregnancy.) 

5.  Nervous  System. — The  changes  are  purely  junctional,  and  disappear 
quickly  after  delivery.  The  nervous  system  becomes  more  impressionable. 
The  changes  in  the  special  senses  are  chiefly  characterized  by  increased  ex- 
citability. The  list  of  reflex  nervous  phenomena  is  manifold,  and  they  are  even 
seen,  in  a  relatively  slight  degree,  in  young  women  at  the  time  of  ovulation  and 
the  beginning  of  menstruation.  Much  more  will  they  be  excited  by  the  great 
changes  taking  place  in  the  maternal,  organism  in  pregnancy. 

Psychical  Changes. — The  disposition  is  in  some  cases  entirely  altered 
for  the  time  being.  Women  previously  amiable  become  peevish,  fretful,  irritable, 
and  overanxious  about  their  health  and  the  condition  of  the  offspring;  and 
look  forward  with  great  dread  to  the  pangs  of  labor.  Others  are  affected  in 
the  opposite  way,  and  become  buoyant-  in  spirits  and  unusually  cheerful.  This 
difference  seems  to  depend  largely  on  the  intensity  of  the  desire  on  the  part  of 
the  mother  for  a  child.  The  state  of  despondency  which  is  so  common,  espe- 
cially in  the  first  part  of  pregnancy,  may  lead  to  extreme  melancholia  and  even 
develop  into  mania  or  dementia.  This  condition  is  seen  particularly  in  patients 
of  an  intensely  neurotic  organization,  in  those  with  an  hereditary  taint  of  in- 
sanity, or  with  a  history  of  hysteria  or  alcoholism.  It  may  also  follow  severe 
mental  shock  in  pregnancy.  Unhappy  marriages  are  also  a  fruitful  cause  of 
mania  in  gestation.  Hysteria  in  pregnancy  offers  an  excellent  illustration  of 
the  fact  that  the  gravid  state  accentuates  any  defect,  either  physical  or  mental, 
in  the  patient.  It  was  formerly  thought  that  pregnancy  exerted  a  beneficial 
effect  on  a  hysterical  woman,  but  this  is  erroneous.  However,  after  its  occur- 
rence the  patient  should  be  carefully  watched  and  guarded.      The  physician' 


BLOOD;    URINE;  SKIN.  117 

should  encourage  her,  and  as  is  the  case  with  the  insane,  special  attention  should 
be  paid  to  the  nutrition  of  the  sufferer,  and  if  necessary  forced  feeding  should 
be  instituted.  Again,  the  patient  should  be  treated  with  perfect  frankness, 
and  no  deceit  attempted.  -A  careful  physical  examination  before  labor  often 
gives  the  patient  a  feeling  of  confidence  in  her  adviser. 

6.  Blood. — Many  conflicting  views  concerning  the  blood  changes  in  preg- 
nancy have  existed.  The  whole  quantity  is  increased.  It  is  generally  agreed 
that  there  is  a  slight  leucocytosis,  but  as  to  the  increase  or  decrease  in  the  number 
of  red  blood-corpuscles,  there  is  still  a  dispute.  Many  authors  believe  their 
proportion  to  be  decreased,  but  Ahlfeld,  quoting  the  work  of  Reinl,  Schroder, 
Ingerslev,  Fehling,  Mayer,  Wild,  Mochnatscheff,  and  Frommel,  declares  that  they 
are  increased,  as  is  the  liquid  element  of  the  blood.  The  number  of  white  cor- 
puscles, as  has  been  indicated,  are  also  slightly  increased.  The  blood  is  deficient 
in  albumin,  but  increased  decidedly  as  to  its  fibrin  element,  as  well  as  extractive 
matters.  This  fact  explains  the  frequency  of  thrombotic  affections  in  connection 
with  pregnancy  and  delivery.  This  hyperinosis  is  increased  also  after  labor, 
by  the  great  quantity  of  effete  matter  thrown  out  into  the  circulation  of  the 
mother,  to  be  disposed  of  by  her  emunctories.  The  blood  of  the  pregnant  woman 
is  generally  in  a  state  more  like  that  in  anemia  than  plethora,  and  treat- 
ment should  be  applied  accordingly.  Objections  to  the  anemia  theory  have 
been  raised,  on  the  ground  that  pregnancy  is  a  physiological,  and  not  a  patho- 
logical condition.  This  is  ideally  true,  but  owing  to  the  influence  of  many 
factors,  such  as  civilization,  climate,  diet,  and  others,  it  must  be  admitted  that 
the  pregnant  woman  is  seldom  in  a  state  of  perfect  health ;  that  her  condition 
leans  toward  anemia  and  poverty  of  blood,  and  must  be  considered  and  treated 
accordingly. 

7.  Urine. — As  to  the  frequency  of  albuminuria  in  pregnancy,  authorities 
differ,  as  well  as  to  the  amount  of  albumin  commonly  present;  some  declaring 
the  percentage  to  reach  20  or  30.  In  physiological  albuminuria  there  are  no 
tube  casts,  nor  any  morbid  symptoms.  Albuminuria  is  far  more  common  in 
labor  than  in  pregnancy,  and  its  existence  is  explained  by  the  theory  of  renal 
anemia  caused  by  the  reflex  vasomotor  spasm  of  the  renal  arteries,  resulting 
from  the  uterine  contractions.  It  may  occur  early,  before  there  is  any  possi- 
bility of  renal  venous  stagnation  from  pressure,  and  it  is  then  the  result  purely 
of  reflex  irritation.  The  intimate  relation  between  the  nerve  ganglia  of  the 
pelvis  and  the  venous  supply  of  the  kidney  would  explain  this.  The  urine 
exhibits  both  quantitative  and  qualitative  changes.  The  amount  excreted  in 
twenty-four  hours  is  increased  in  quantity  and  decreased  in  specific  gravity, 
due  to  the  hydremic  condition  and  the  high  arterial  tension.  There  is  an  in- 
crease in  the  chlorides,  and  the  phosphates  and  sulphates  are  decreased,  on 
account  of  their  use  in  the  development  of  the  fetus.  Chalvet  and  Barlemont 
found  a  decrease  also  in  the  urea,  uric  acid,  creatin,  and  creatinin;  these  may 
also  pass  over  to  the  fetus  (Lehmann  and  Donne).  (For  Albuminuria  and 
Pregnancy-kidney  see  Part  III.) 

8.  Skin. — The  functions  of  the  glands  of  the  skin — sebaceous,  sweat,  and  hair 
follicles — are  increased  in  gestation.  Pigmentary  spots  over  the  body  are  com- 
mon. Patches  of  yellowish-brown  color  over  the  face  are  known  as  chloasma 
or  the  "mask  of  pregnancy."  The  abdomen  and  breasts  are  also  darkly  pig- 
mented in  areas.  The  lineae  albicantiae  are  very  marked.  Many  women  will 
have  on  the  abdomen  a  brown  area  of  about  two  fingers'  breadth,  extending 
from  the  mons  veneris  to  the  umbilicus,  which  it  sometimes  surrounds,  and 
beyond  to  the  xiphoid  cartilage.     This  band  is  more  distinct  below  than  above 


118 


PHYSIOLOGICAL  PREGNANCY. 


-3?<i|| 


the  navel  (Fig.  i6i).  The  circle  around  the  latter  is  known  as  the  "umbilical 
areola"  (Fig.  i6i).  The  mammary  areolae,  both  primary  and  secondary,  have 
been  described.  These  pigmentations  undergo  many  variations  in  extent  and 
degree  in  different  patients.  Brunettes  show  them  more  plainly  than  blondes. 
The  pigmentation  of  the  vulva,  as  a  sign  of  early  pregnancy,  has  also  been 
referred  to.  These  deposits  seldom  disappear  entirely,  but  they  are  less  after 
labor.  Abdominal  striae,  or  silvery  streaks  or  white  lines,  are  seen  on  the  abdom- 
inal wall  as  the  result  of  the  first  pregnancy ;  and  it  is  not  uncommon  to  observe 
the  formation  of  new  ones  in  subsequent  pregnancies  (Fig.  i6i).     They  may 

also  be  seen  on  the  hips,  thighs,  and 
breasts  (Fig.  i6i).  These  markings 
are  at  first  of  a  pinkish  or  bluish-red 
tint,  but  after  parturition  they  be- 
come white  or  pearl-colored.  They 
are  due  to  the  partial]  rupture  and 
atrophy  of  the  connective  tissue  of 
the  deep  layers  of  the  distended  skin. 
They  are  not  peculiar  to  pregnancy, 
but  occur  even  on  men  after  the  skin 
has  been  subjected  to  much  stretch- 
ing, as  in  ascites,  etc.  The  skin -cover- 
ing the  umbilical  depression,  in  the 
first  three  months  of  intrauterine  ges- 
tation, is  drawn  inward  and  down- 
ward, by  the  traction  on  the  urachus, 
the  ligament  following  the  descent  of 
the  bladder  occasioned  by  the  early 
sinking  of  the  uterus.  The  navel  now 
presents  a  pit  or  depression.  This 
causes  a  dragging  sensation ;  when  the 
uterus  begins  to  rise  out  of  the  pelvis, 
the  navel  resumes  its  former  appear- 
ance. During  the  fourth,  fifth,  and 
sixth  months  the  depression  becomes 
progressively  shallower,  till  at  the 
seventh  it  is  on  a  level  with  the  skin, 
the  ring  being  at  the  same  time  dilated 
so  as  to  admit  the  end  of  the  finger. 
During  the  last  two  months  the  um- 
bilicus may  actually  form  a  protuber- 
ance, and  this  condition  is  known  as 
"pouting  of  the  navel."  Not  in- 
frequently, if  the  woman  overexert  herself,  an  umbilical  hernia  will  be  formed. 
9.  Gait. — The  gait  of  a  pregnant  woman  undergoes  change,  for  in  order  to 
preserve  the  center  of  gravity,  the  head  and  shoulders  must  be  thrown  back- 
ward.    Short  women  show  this  change  most  markedly. 

10.  Delay  of  Bony  Repair. — On  account  of  the  drain  by  the  fetus  on  the 
mother's  osseous  elements,  fractured  bones  unite  slowly. 

11.  Temperature. — The  temperature  in  pregnancy  remains  unchanged. 
Some  authorities,  however,  believe  it  to  be  lower  in  the  morning  than  later 
in  the  day. 


!> 


Fig.  i6i.^Pregnancy  at  the  Thirty-eighth 
Week  showing  Stride  and  Pigmentation 
OF  Thighs,  Abdomen,  and  Breasts,  and 
Right  Lateral  Obliquity  of  the  Uter- 
us.— (From  author's  photograph  at  the  Emer- 
gency Hospital.) 


THE    DIAGNOSIS   OF  PREGNANCY.  119 


111.   THE  DIAGNOSIS  OF  PREGNANCY. 

Importance. — The  importance  of  expert  diagnosis  in  cases  of  suspected 
pregnancy  is  very  apparent.  There  are  no  mistakes  in  a  physician's  experience 
so  hard  to  hve  down  as  those  made  in  this  department  of  medicine,  and  none 
that  excite  harsher  criticism,  or  greater  ridicule  for  the  diagnostician.  Apart  from 
these  less  important  considerations,  it  must  be  remembered  that  the  knowledge 
of  the  existence  of  pregnancy  is  often  of  the  greatest  importance  to  the  life  of 
the  patient,  both  in  the  field  of  medicine  and  that  of  surgery.  A  physician  can 
sometimes  render  incalculable  service  by  being  able  skilfully  and  honestly  to  ex- 
clude the  possibility  of  pregnancy;  and,  on  the  contrary,  he  can  do  great  harm 


"fw^lj^^'ljiy" 


Fig.  162. — Position  of  the  Fingers  for  Vaginal  Examinations  and  Manipulatioms. 

— (Photograph.) 

and  cause  much  misery  by  expressing  the  opposite  opinion  in  a  case  innocent 
of  this  condition,  the  opinion  being  based  on  a  careless  or  ignorant  interpreta- 
tion of  the  signs  presented.  The  medico-legal  value  attaching  to  this  question 
is  often  important. 

A  number  of  symptoms  and  signs  taken  together  give  certain  evidence  of 
the  presence  of  pregnancy;  and  single  signs,  especialty  in  the  latter  part  of  preg- 
nancy, render  the  diagnosis  probable  or  even  positive.  The  physician,  how- 
ever, will  always  do  well  to  be  reserved  in  the  expression  of  his  opinion,  if  there 
is  any  doubt  as  to  the  condition.  The  diagnosis  depends  upon  the  physician's 
ability  to  group  the  symptoms  in  the  order  of  their  importance,  and  upon  his 
familiarity  with   all  the  methods  of  examination.     The  difficulties  of  diagnosis 


120 


PHYSIOLOGICAL  PREGNANCY. 


will  be  considered  later,  under  the  head  of  differential  diagnosis.  Mistakes 
should  be  avoided  by  the  greatest  care  in  the  details  of  the  examination.  With 
all  these  precautions,  there  are  on  record  numerous  cases  which  exemplify  the 
striking  errors  of  eminent  specialists. 

The  physical  signs  are  of  far  more  importance  and  value  than  the  symptoms, 
and  are  obtained  by  means  of  sight,  touch,  and  hearing.  There  is  much  room 
for  deception  in  the  patient's  account  of  herself,  for  she  may  intentionally  or 
unintentionally  misrepresent  one  or  all  of  her  symptoms.  But  the  informa- 
tion which  is  obtained  by  inspection,  palpation,  percussion,  and  auscultation, 
lacks  the  uncertain  element  always  present  in  the  personal  history,  and  gives 
data  that  can  be  relied  upon.  Upon  the  period  of  the  pregnancy  will  depend 
to  a  certain  extent  the  satisfactory  results  of  the  examination.  For  the  prepara- 
tion and  posture  of  the  patient  for  the  examination  see  Obstetric  Examina- 
tion. 

Classification. — The   symptoms    and   physical   signs   of   pregnancy   may   be 


Fig.  i63.^Right  and  Left  Halves  of  a  Frozen  Section  of  a  Uterus  at  Two  and  a 
Half  Months,  showing  Changes  in  Shape  and  Density  of  the  Uterine  Walls 
AND  Thick  Decidua. — (After  Pinard.) 


conveniently  classified  as:  (i)  Uterine;  (2)  vaginal;  (3)  abdominal;  (4)  mam- 
mary; (5)  fetal;  (6)  sympathetic  and  reflex;  (7)  due  to  pressure  and  congestion; 
(8)  cutaneous;  (9)  individual  and  subjective. 

I.  Uterine. — (i)  Cessation  of  Menstruation. — This,  as  a  general  rule, 
is  the  first  warning  of  pregnancy  to  women  who  have  been  exposed  to  impregna- 
tion. It  is  not  a  perfectly  trustworthy  symptom,  for  it  may  occur  in  various 
diseases  and  conditions.  However,  when  occurring  in  healthy  women  who 
have  previously  menstruated  regularly,  it  is  strongly  presumptive  of  pregnancy, 
and  it  is  of  great  practical  value,  as  it  probably  offers  the  most  reliable  datum 
for  predicting  the  date  of  confinement.  Nevertheless,  certain  errors  must 
be  guarded  against  in  relation  to  this  symptom,  for  various  chronic  diseases, 
such  as  tuberculosis,  anemia,  syphilis,  and  some  acute  affections,  such  as  diph- 
theria, pneumonia,  and  dysentery,  may  cause  a  cessation  of  the  menstrual  flow, 
either  permanently  or  temporarily.  Change  of  climate ;  exposure  to  cold;  mental 
emotions;  general  debility;  excessive  desire  to  become  pregnant,  as  in  the  newly 


THE  DIAGNOSIS  OF  PREGNANCY. 


121 


married;  or  a  fear  of  becoming  so  in  the  unmarried  who  have  exposed  them- 
selves to  impregnation — all  these  causes  may  be  instrumental  in  bringing  about 
a  cessation  of  the  menses.  Pregnancy  may  occur  in  cases  in  which  menstruation 
is  absent,  as  in  women  during  lactation;  while  it  has  been  known  to  occur  in 
young  girls  before  this  function  was  estab-  • 
lished.  A  few  authentic  cases  are  recorded 
of  the  occurrence  of  conception  after  the 
climacteric;  and,  again,  of  the  continuance 
of  the  menstrual  periods  during  pregnancy, 
or  of  what  is  thought  to  be  menstruation  by 
the  patient.  At  the  same  time  there  may 
be  hemorrhages  due  to  pathological  condi- 
tions of  the  internal  genital  tract,  as  from 
the  vagina,  mucous  membrane  of  the  cer- 
vix, decidua,  chorion,  polypi,  or  placenta 
praevia.  If  menstruation  pure  and  simple 
does  occur  during  pregnancy,  it  may  easily 
be  explained  by  the  anatomical  condition 
of  the  growing  uterus  with  its  contents. 
(See  Development  of  the  Ovum,  page  46.) 
(2)  Changes  in  Volume,  Shape,  and 
Position. — In  palpating  the  uterus  in 
search  of  the  signs  of  pregnancy,  the  bi- 
manual or  conjoined  method  is  preferable  to  simple  palpation  with  one  hand,  or 
vaginal  touch,  as  it  is  called ;  and  of  the  bimanual  methods,  the  abdomino-vaginal 
is  most  useful,  and  most  often  used,  but  the  abdomino-rectal  is  occasionally  of 
value,  especially  in  primigravidas.  The  physical  signs  arising  from  the  progres- 
sive growth  of  the  uterus,  causing  alterations  in  volume,  shape,  and  position 


Fig.  164. — First  Method  of  Elicit- 
ing Hegar's  Sign  of  Pregnancy. — 
(Sonntag.) 


Fig.    165. — Second    Method  of    Eliciting 
Hegar's  Sign  of  Pregnancy. — {Sonntag.) 


Fig.  166. — Third  Method  of  Eliciting 
Hegar's  Sign  of  Pregnancy. — (Sonn- 
tag.) 


of  the  organ,  have  already  been  described  under  "The  Local  Changes  Produced 
by  Pregnancy,"  page  91,  and  famiHarity  with  these  changes  should  be  acquired 
by  the  student.  At  the  same  time,  other  causes  of  uterine  enlargement  may 
simulate  pregnancy,  as  subinvolution,  inflammation  of  the  uterus  and  peri-uterine 


122 


PHYSIOLOGICAL  PREGNANCY. 


Fig.  167. — Position  of  the  Two  Hands  in  the  Bimanual  Examination  for  the  Diag- 
nosis OF  Pregnancy. 


Fig.  168. — Bimanual  Examination  with 
THE  Hand  on  the  Fundus  and  One 
Finger  in  the  Left  Lateral  Vaginal 
Fornix. 


Fig.  i6q. — Bimanual  Examination  with 
the  Hand  on  the  Fundus  and  a 
Finger  in  Each  Vaginal  Fornix. 


THE  DIAGNOSIS  OF  PREGNANCY.  123 

tissues,   and  intramural  tumors  of   the  organ.     (See  Differential  Diagnosis  of 
Pregnancy.) 

(3)  Changes  in  Consistency. — (a)  Progressive  softening  of  the  cervix,  which 
begins  at  the  external  os,-and  gradually  extends,  until  by  the  end  of  pregnancy 
the  whole  cervix  is  included  in  a  velvety  softness  due  to  serous  infiltration. 
Beginning  softening  can  often  be  detected  as  early  as  the  second  or  third  week; 
on  this  change  Goodell  founded  the  rule  that,  when  the  cervix  is  as  hard  as  the 
tip  of  one's  nose,  pregnancy  presumably  does  not  exist;  but  if  it  be  as  soft  as 
one's  lips,  pregnancy  is  probable.  (6)  Softening  and  compressibility  of  the  lower 
uterine  third  constitute  Hegar's  sign.  This  is  of  great  value,  and  has  been  ob- 
served by  the  sixth  or  eighth  week.  It  consists  in  alteration  in  the  consist- 
ency and  shape  of  the  region  of  the  uterus  situated  just  above  the  cervix — a 
change  that  is  most  striking  in  the  middle  division  of  the  lower  uterine  third. 
This  part  of  the  uterus  seems  at  times  hardly  thicker  than  ordinary  cardboard, 
and  it  would  appear  almost  as  if  the  fundus  and  the  cervix  were  separate  tumors. 
The  shape  is  also  changed,  the  lower  uterine  third  widening  abruptly  above 
the  cervix,  and  not  gradually,  as  in  the  normal  pear-shaped  uterus.  These 
alterations  are  far  more  difficult  to  recognize  in  women  who  have  already  borne 
one  or  more  children,  but  when  well  marked  are  absolutely  indicative  of  a 
pregnant  uterus.  The  detection  of  these  changes  requires  a  certain  degree  of 
skill  in  the  performance  of  the  bimanual  examination,  and  also  of  familiarity 
with  the  sensations  communicated  to  the  finger  by  the  non-pregnant  uterus 
of  women  who  have  never  borne  children,  by  the  non-pregnant  uterus  of  women 
who  have  borne  several  children,  and  also  by  the  uterus  altered  by  certain 
pathological  conditions.  Method  of  examination:  (a)  In  a  patient  whose  abdom- 
inal walls  are  lax  and  thin  and  whose  vagina  is  roomy,  the  two  fingers  are  intro- 
duced into  the  vagina,  and  passed  high  up  behind  the  cervix,  w^hile  the  other 
hand  presses  down  into  the  abdomen  from  above  and  behind  the  pubes  (Fig. 
167).  (b)  But  if  the  fundus  should  be  decidedly  antefiexed,  the  vaginal  finger 
should  be  passed  up  in  front  of  the  cervix,  while  the  external  hand  presses  down 
the  fundus  (Fig.  167).  (c)  Where  the  favorable  conditions  of  lax  abdominal 
parietes  and  capacious  vagina  are  not  present,  the  index-finger  is  passed  into  the 
rectum,  while  the  thumb  is  inserted  into  the  vagina  in  front  of  the  cervix.  The 
other  hand,  in  the  meanwhile,  exerts  pressure  on  the  abdomen  behind  the 
pubes.  (d)  Still  another  method  is  feasible:  with  the  internal  hand  in  the  same 
position  as  in  the  last  method,  the  external  hand  presses  the  fundus  uteri  down- 
ward. Sometimes  the  cervix  is  pulled  down  by  a  tenaculum.  Between  the 
second  and  fifth  months  of  pregnancy  30  per  cent,  of  the  cases  may  be  recognized 
by  this  sign.  Anesthesia  is  rarely  required  in  order  to  conduct  these  examina- 
tions. There  are  diseased  conditions  of  the  wall  of  the  uterus  in  which  this  sign 
cannot  be  obtained,  even  though  pregnancy  exists,  (c)  Consistency  of  body  of 
uterus.  Pregnancy  changes  the  rigid,  firm,  inelastic  condition  of  the  non-pregnant 
uterus,  to  an  elastic,  resilient  state  which  increases  with  the  advance  of  preg- 
nancy, until  the  fetus  is  contained  in  a  flexible,  elastic-walled  cavity.  The 
peculiar  sensation  imparted  by  a  uterus  enlarging  from  pregnancy  is  most  char- 
acteristic (Fig.  163).     (See  Local  Changes  Produced  by  Pregnane}'.) 

(4)  Intermittent  Contractions — Braxton  Hicks's  Sign. — These  may  be 
detected  by  palpation  as  early  as  the  fourth  month.  If  the  hand  is  placed 
in  full  contact  with  the  abdominal  contour  of  the  uterus,  friction  and  pressure 
being  absent,  and  retained  there  for  from  five  to  twenty  minutes  or  less,  the 
gradual  relaxation  or  contraction  of  the  uterine  musculature  will  be  felt.  These 
contractions  as  a  rule  occur  every  five  or  six  minutes,  while  the  duration  of  each 


124  PHYSIOLOGICAL  PREGNANCY. 

contraction  is  from  two  to  five  minutes.  Braxton  Hicks  says  that  "if  an  abdom- 
inal tumor  thus  changes  in  density  and  hardness  we  may  be  sure  that  the  tumor 
is  the  uterus."  But  Lanier  has  shown  that  the  same  sensations  of  intermittent 
contractions  may  be  obtained  from  a  distended  bladder.  Soft  fibroids  of  the 
uterus  also  give  these  sensations,  as  well  as  do  the  uterine  efforts  to  expel  blood- 
clots,  polypi,  or  retained  menses.  However,  when  taken  in  connection  with 
the  other  signs  of  pregnancy,  this  sign  is  of  great  value. 

(5)  Uterine  Murmur,  Souffle,  or  Bruit. — This  sound  was  also  wrongly 
called  the  "  placental  souffle  "  or  "  murmur,"  or  bruit  placentaire,  by  those  who 
regarded  it  as  due  to  blood  rushing  through  the  placental  sinuses.  Again,  it 
has  been  called  abdominal  souffle  by  others,  who  think  it  due  to  pressure  of 
the  pregnant  uterus  upon  the  large  abdominal  vessels.  The  sound  is  a  single 
murmur,  synchronous  with  the  first  sound  of  the  maternal  heart.  Its  quality 
varies,  sometimes  being  gentle,  murmuring,  blowing  or  musical,  resembling 
very  much  the  sound  produced  by  pronouncing  "voo"  in  a  low  tone.  At  other 
times  it  is  harsh,  loud,  and  scraping;  while  again  it  may  be  sibilant,  or  sonorous. 
Its  rhythm  may  be  continuous  and  regular,  corresponding  with  the  mother's 
pulse,  or  it  may  be  distinctly  irregular.  After  once  being  heard,  it  may  dis- 
appear for  a  few  minutes  or  for  several  days,  and  its  position  is  very  apt  to  shift. 
Sometimes  it  will  persist  in  a  circumscribed  spot;  again  in  two  spots,  one  on 
either  side  of  the  uterus;  or,  again,  it  will  be  diffused  over  the  whole  anterior 
abdominal  region.  The  weight  of  authority  is  to  the  effect  that  this  sound 
originates  in  the  uterine  blood  channels.  The  murmur  has  been  observed  several 
days  after  the  birth  of  the  placenta,  and  no  legitimate  proof  of  its  origin  in 
the  abdominal  vessels  has  been  offered.  Aside  from  its  variation  in  position, 
it  frequently  varies  in  duration,  intensity,  tone,  and  pitch.  It  is  most  frequently 
detected  at  the  lower  part  of  the  abdomen,  and  this  would  of  necessity  be  the 
case  in  the  early  part  of  gestation.  Feebleness  or  death  of  the  fetus  has  no 
effect  upon  it.  Only  an  expert  can  recognize  it  before  the  sixteenth  week. 
It  is  not  a  positive  sign  of  pregnancy,  for  similar  sounds  may  be  heard  in  ovarian 
or  uterine  tumors  of  large  size.  In  labor  it  is  stronger  at  the  beginning  of  a 
pain,  ceasing  altogether  at  its  height,  and  returning  again  as  the  pain  declines. 

(6)  Uterine  Fluctuation — Rasch's  Sign — may  be  detected  as  early 
as  the  second  month  of  pregnancy.  As  in  ballottement,  two  fingers  of  the 
left  hand  are  introduced  into  the  anterior  vaginal  fornix,  while  the  right  hand 
firmly  grasps  the  fundus.  Tapping  by  the  fingers  of  the  external  hand  will 
transmit  an  impulse  to  the  internal  fingers,  the  wave  being  transmitted  through 
the  liquor  amnii.  This  sign,  considered  by  many  to  be  of  diagnostic  value,  must 
not  be  confounded  with  Hegar's. 

(7)  Asymmetry  of  the  Corpus  Uteri. — The  fact  has  often  been  noted  that 
at  a  very  early  period  of  pregnancy  the  corpus  uteri  is  asymmetrical,  one  side 
being  thicker  than  the  opposite;  while  the  bulging  portion  is  marked  off  from 
the  rest  of  the  corpus  by  a  furrow  (Fig.  163).  This  bulge  may  appear  upon  any 
portion  of  the  body  of  the  organ.  There  is  also  a  difference  in  the  density  of  the 
two  portions,  the  prominence  being  dense  and  firm,  while  the  rest  of  the  corpus 
feels  elastic  (Fig.  163).  Braun-Fernwald,  who  has  studied  this  sign  with  great 
care,  believes  that  this  asymmetry  of  the  uterus  is  a  necessary  result  of  the 
implantation  of  the  ovum  upon  one  side  of  the  uterine  cavity.*  Many  authori- 
ties believe  that  this  is  the  earliest  and  most  constant  uterine  sign  of  pregnancy. 

(8)  Uterine  Pulse. — The  claim  has  been  made  that  the  pulse  of  the 
uterine  artery,  which  is  ordinarily  impalpable,  may  be  recognized  early  in  preg- 

*"Wien.  klin.  Woch.,"  1899,  No.  10. 


THE   DIAGNOSIS   OF   PREGNANCY.  125 

nancy.     To  elicit  this  sign  the  organ  should  be  depressed  and  the  artery  felt 
for  high  up  in  the  lateral  cul-de-sac. 

2.  Vaginal. — (i)  Purplish  Discoloration  of  the  Vaginal  and  Vulval 
Mucous  Membranes — Jacquemier's  Sign:  Congestion  of  the  vulval  and 
vaginal  blood-vessels  causes,  as  early  as  the  sixth,  but  frequently  not  until 
the  twelfth  week,  first  a  violet  or  light  blue,  and,  as  pregnancy  advances,  a 
purplish  or  deep  blue  tint  of  the  mucous  membrane  (Fig.  7).  In  the  vulval 
canal  the  sign  is  most  intense  just  below  the  urethral  orifice.  This  is  one  of 
the  probable  signs  of  gestation.  It  is  true  that  pelvic  inflammation  and  tumors 
may  produce  the  sign,  but  rarely  to  the  degree  caused  by  pregnancy.  (2) 
Increased  Secretion:  The  vaginal  discharges  are  normally  increased  during 
pregnancy,  coincident  with  the  hypertrophy  of  the  mucous  membrane,  and  a 
condition  may  arise  in  the  perfectly  healthy  pregnant  woman  which  would  be 
known  in  the  non-gravid  subject  as  catarrhal  vaginitis.  This  is  especially 
common  in  the  latter  half  of  gestation.  The  discharge  is  whitish  and  may  be 
profuse  enough  to  alarm  the  patient.  Endotrachelitis  may  also  be  the  cause 
of  a  vaginal  discharge  during  pregnancy.  (3)  Temperature:  The  sensation 
of  increased  heat  in  the  genitalia  is  an  important  sign.  It  is  due  to  the  augmented 
blood  supply  to  those  parts,  to  the  pathological  condition  of  vaginitis,  or  to 
congestive  diseases  of  the  pelvic  viscera.  (4)  Vaginal  Pulse — Osiander's 
Sign:  During  and  after  the  middle  third  of  gestation  a  distinct  pulsation  of 
the  vaginal  arteries,  due  to  local  high  arterial  tension,  may  be  made  out;  while 
not  a  positive  sign  of  pregnancy,  this  is  a  probable  one,  and  is  of  value  in  con- 
junction with  others.  Non-pregnant  conditions,  as  fibroids  and  pelvic  inflam- 
mations, may  give  rise  to  the  same  sign. 

3.  Abdominal. — (i)  Progressive  Enlargement:  In  the  beginning  of 
pregnancy  there  is  hypogastric  flattening,  due  to  the  sinking  of  the  uterus  from 
its  increased  weight.  Later  the  abdomen  enlarges,  becoming  the  shape  of  a 
pear,  with  the  smaller  end  downward.  The  enlargement  first  becomes  notice- 
able at  the  fourth  month.  The  tumor  is  then  in  the  median  line,  but  later  tends 
to  the  right.  The  uterus  rises  about  two  fingers'  breadth  every  four  weeks. 
At  the  end  of  the  third  month  the  fundus  uteri  is  about  on  a  level  with  the  top 
of  the  symphysis.  During  the  fourth  month  it  occupies  the  hypogastrium ; 
at  the  fifth  it  is  half-way  between  the  symphysis  and  umbilicus;  b}^  the  sixth 
it  is  at  the  umbilicus  or  just  above;  by  the  seventh  it  is  half-way  between  the 
umbilicus  and  ensiform  cartilage.  It  reaches  the  ensiform  by  the  eighth  month, 
where  it  remains  for  about  two  weeks,  then  sinks  a  trifle  in  the  last  two  weeks 
of  pregnancy.  It  is  hardly  necessary  to  state  that  this  is  merely  a  doubtful 
sign,  as  abdominal  enlargement  closely  simulating  pregnancy  may  be  due  to 
many  pathological  conditions,  such  as  uterine  fibroids,  excessive  deposition  of 
fat  in  the  abdominal  walls,  tympanites,  ovarian  cysts,  and  other  abdominal 
tumors.  (2)  Pigmentation  (Fig.  161):  This,  as  I  have  repeatedly  demonstrated 
in  the  clinic,  is  in  some  women  entirely  absent,  thus  giving  us  only  a  doubtful 
sign  of  pregnancy.  It  has  also  been  observed  in  cases  of  ovarian  irritation, 
at  the  menstrual  periods,  and  in  myomata  of  the  uterus.  (3)  Stri^  (Fig.  i6t  ) : 
They  give  us  only  an  uncertain  sign  of  pregnancy,  as  they  may  result  from 
excessive  non-pregnant  enlargement  of  the  abdomen.  They  are  found  even 
in  the  male.  (4)  Abdominal  Ballottement:  During  the  middle  third  of  preg- 
nancy, by  placing  the  hands  upon  both  sides  of  the  abdomen,  where  the  muscles 
are  not  too  tense,  the  fetus  may  be  passed  back  and  forth  between  the  two 
hands  by  a  series  of  gentle  but  decided  pushes  or  taps.  This  is  known  as  "  ab- 
dominal ballottement."     A  tense,  resisting  abdominal  wall,  or  one  loaded  with 


126  PHYSIOLOGICAL  PREGNANCY. 

fat,  will  obscure  all  the  signs  of  pregnancy  obtainable  by  palpation.  (5)  Fluc- 
tuation: In  the  last  third  of  pregnancy,  if  the  palm  of  one  hand  be  placed  upon 
one  side  of  the  abdomen,  while  the  opposite  side  is  lightly  tapped,  distinct 
fluctuation  may  in  some  cases  be  elicited.     This  is  naturally  an  uncertain  sign. 

(6)  Changes  in  the  Percussion-note  and  Umbilicus:  Percussion  should 
not  be  neglected  in  the  examination  for  pregnancy.  This  method  will  yield 
only  negative  signs  before  the  end  of  the  third  month.  In  practising  percussion 
in  early  pregnancy,  care  should  be  taken  not  to  mistake  the  flatness  produced 
by  a  distended  bladder  for  a  pathological  tumor  of  the  pelvis  or  abdomen. 
Generally  the  dullness  of  the  uterine  body  can  be  detected,  surrounded  on  three 
sides  by  the  tympanitic  intestines.  Now  and  then,  however,  a  few  intestinal 
coils  will  interpose  themselves  between  the  uterus  and  the,  anterior  abdominal 
wall,  and  give  a  tympanitic  resonance  in  response  to  tapping.  (For  changes 
in  the  umbilicus,  see  page  118.) 

4.  Mammary. — The  physical  signs  include  (i)  general  enlargement;  (2) 
prominence  of  the  veins;  (3)  pigmentation,  forming  primary  and  secondary 
areolae;  (4)  enlargement  of  the  tubercles  of  Montgomery;  (5)  prominence,  erec- 
tion, turgescence,  and  bran-like  scales  of  the  nipple;   (6)  formation  of  striae; 

(7)  secretion  of  colostrum.  The  presence  of  secretion  is  the  most  valuable  of 
the  foregoing  signs,  and  in  primigravidous  women  it  is  a  probable  sign  of  gesta- 
tion. In  multigravidse  it  becomes  uncertain,  though  the  suppression  of  milk 
in  a  nursing  woman  has  considerable  importance  in  corroborating  other  signs. 
Taken  alone,  these  signs  are  not  trustworthy;  their  absence  does  not  prove 
the  non-existence  of  pregnancy;  they  should  be  supplemented  by  more  positive 
signs.  Uterine  or  ovarian  diseases  may  be  accompanied  by  many  of  them,  or 
they  may  persist  a  long  while  after  delivery.  (See  Local  Changes  Produced 
by  Pregnancy,  page  89.)  The  advantage  of  mammary  changes  over  other 
objective  signs  consists  in  their  early  and  almost  inevitable  occurrence,  and 
in  the  possibility  of  examining  the  patient's  breasts  without  rousing  her  sus- 
picion. 

5.  Fetal. — (i)  Quickening:  This  term  arose  from  the  former  erroneous 
notion  that  at  the  time  when  the  mother  became  conscious  of  the  spontaneous 
movements  of  the  fetus,  life  was  imparted  to  the  fetus.  The  active  fetal  move- 
ments are  generally  first  felt  by  the  mother  at  the  end  of  the  sixteenth  week. 
Although  perceived  by  the  patient  at  such  a  comparatively  late  period,  they 
really  occur  very  early  in  embryonal  existence,  i.  e.,  as  soon  as  the  muscular 
tissue  is  sufficiently  developed  to  contract.  The  commonly  accepted  idea  is  that 
they  are  first  perceived  by  the  mother  when  the  uterus  has  expanded  suffi- 
ciently to  come  in  contact  with  the  anterior  abdominal  wall,  and  thus  the  fetal 
movements  are  transmitted  to  her  sensory  nerves.  They  have  been  compared, 
when  first  felt,  to  the  fluttering  of  a  bird  imprisoned  in  the  hand.  With  ad- 
vancing gestation  these  movements  increase  in  vigor,  and  may  even  become 
painful,  consisting  of  sharp,  short  strokes,  or  kicks.  They  greatly  increase  after 
fasting,  and  just  before  fetal  death  by  asphyxia.  They  may  cease  entirely, 
and  the  fetus  still  remain  in  perfect  condition,  although  their  sudden  and  com- 
plete cessation  is  often  coincident  with  the  death  of  the  child.  In  some  cases 
these  movements  have  never  been  detected  by  either  mother  or  physician,  and 
yet  at  term  a  perfectly  healthy  child  has  been  delivered.  Pathological  conditions, 
such  as  hydramnios  and  ascites,  may  either  partly  or  wholly  obscure  these  motions. 
This  sign,  considered  as  a  subjective  symptom,  is  open  to  many  errors,  for 
irregular  muscular  contractions  of  the  abdominal  muscles,  the  peristalsis  of  the 
intestines,  especially  when  the  latter  are  full  of  gas,  or  a  wandering  kidne3^ 


THE  DIAGNOSIS  OF  PREGNANCY.  127 

may  cause  similar  sensations.  However,  some  little  value  attaches  to  it  from 
the  fact  that  its  first  occurrence  furnishes  a  certain  datum  for  the  calculation 
of  the  time  of  confinement.  .  When  the  physician  himself  feels,  or  sees,  or  hears 
these  movements,  they  constitute  a  sure  sign  of  the  existence  of  pregnancy, 
and  of  the  viability  of  the  child.  No  other  movement,  normal  or  abnormal, 
occurring  in  the  abdomen  can  ever  give  a  like  sensation  to  the  hand  of  the 
examiner.  After  their  first  detection  by  the  physician,  and  as  gestation  ad- 
vances, they  may  not  only  be  felt  but  also  seen  or  heard.  Prior  to  the  fourth 
month,  the  methods  of  bimanual  palpation,  or  vaginal  stethoscopy,  may  elicit 
them  occasionally,  but  after  that  time  abdominal  palpation  is  used.  Among 
these  movements  should  be  included  fetal  hiccough. 

(2)  Palpation  of  the  Fetus. — About  the  middle  of  pregnancy  the 
uterus  will  have  become  so  elastic,  thinned,  and  compressible  that  we  are  able 
upon  palpation  to  make  out  the  fetus,  which  is  now  large  enough  to  be  recognized 
by  the  abdominal  touch.  At  the  end  of  pregnancy  this  is  of  great  value  in 
detecting  the  various  positions  of  the  child.  Movements  of  the  fetus  may  be 
seen  by  the  eye  or  felt  with  the  hand.  In  examining  for  fetal  movements,  the 
palm  of  the  hand  is  placed  upon  the  abdomen,  and  steady  downward  pressure  is 
kept  up  for  some  moments.  Should  the  movements  not  be  felt,  pressure,  or  a 
series  of  gentle  raps  with  the  other  hand  about  the  first,  will  generally  suffice  to 
produce  them. 

(3)  Heart  Sounds. — Mayor,  of  Geneva,  in  1818,  discovered  that  upon 
applying  the  ear  to  the  abdomen  of  the  pregnant  woman  the  fetal  heart  sounds 
could  be  heard,  and  thus  the  most  important  sign  of  pregnancy  was  brought 
to  light.  Kergaradec,  of  Lausanne,  ignorant  of  the  discovery  of  Mayor,  an- 
nounced the  same  fact  three  years  later,  in  1821.  The  discovery  was  accidental 
in  each  case.  Auscultation  in  obstetrics  furnishes  the  only  sign  of  pregnancy 
which,  in  itself,  and  in  the  absence  of  all  others,  is  perfectly  reliable;  namely,  the 
heart  sounds  of  the  fetus.  These  sounds  are  first  heard  about  the  middle  of  the 
fourth  month.  They  consist  of  two  sounds  or  beats, — a  first  sound  and  a  second 
sound.  These  two  are  separated  by  a  slight  interval,  the  first  sound  being  the 
louder,  longer,  and  more  distinct;  the  second  often  being  almost  inaudible. 
The  usual  simile  used  in  illustration  is  the  ticking  of  a  watch  heard  through  a 
pillow.  While  the  rapidity  of  this  sound  continues  the  same  throughout  preg- 
nancy, the  intensity  and  strength  steadily  increase.  The  rapidity  and  intensity  of 
the  fetal  heart  sounds  may  temporarily  be  increased  or  diminished;  thus,  the 
movements  of  the  child  may  accelerate  the  pulse  several  beats  per  minute,  and 
at  the  same  time  increase  its  intensity.  On  the  other  hand,  during  labor  and 
after  the  escape  of  the  liquor  amnii,  the  contractions  of  the  uterine  walls  ma}^ 
greatly  depress  the  heart,  and  this  fact  is  one  indication  for  interference  in  pro- 
longed or  retarded  labors.  The  position,  or  point  of  the  greatest  intensity,  of  the 
fetal  heart  sounds  will  vary  with  the  position  of  the  child  in  the  uterus.  In  head 
presentations  the  fetal  heart  is  most  frequently  heard  at  a  point  half-way  between 
the  umbilicus  and  the  left  anterior  superior  spine  of  the  ilium,  the  reason  for 
this  being  that  the  most  frequent  position  of  the  fetus  is  with  its  back  anterior 
and  directed  a  little  to  the  left  side  of  the  mother.  The  next  most  frequent 
site  will  be  on  the  same  level,  but  upon  the  right  side.  In  breech  cases,  on  the 
other  hand,  the  fetal  heart  is  best  heard  above  the  umbilicus,  on  either  side 
of  the  median  line,  according  to  the  position  of  the  child,  the  sound  of  the  heart 
being  naturally  heard  with  greatest  intensity  at  that  point  where  the  back  of 
the  child  touches  the  uterine  wall.  Like  all  vascular  sounds,  it  is  transmitted 
better  through  solid  than  fluid  media.     When  the  fetal  heart  sounds  are  heard 


12S 


PHYSIOLOGICAL  PREGNANCY. 


distinctly,  they  furnish  an  absolute  and  certain  physical  sign  of  pregnancy.  It 
is  the  surest  sign,  and  is  readily  recognized  after  the  fourth  month.  It  is  entirely 
beyond  the  control  of  the  patient.  The  only  other  sign  of  equal  value  is 
recognition  of  the  fetus  by  abdominal  or  vaginal  palpation.  The  sound  of 
the  fetal  heart  not  only  makes  it  positive  that  pregnancy  is  present,  but  also 
that  the  child  is  living.  The  fact  that  it  is  not  heard,  however,  does  not  nega- 
tive pregnancy,  for  the  fetus  may  be  dead,  or  the  sounds  for  a  time  inaudible; 
the  maternal  abdominal  walls  may  be  very  thick  and  fat;  the  fetal  back  may 
be  posterior;  the  intestines  may  be  full  of  gas;  hydramnios  may  be  present.  The 
rate  of  the  fetal  heart  sounds  and  that  of  the  mother's  do  not  correspond.  The 
fetal  heart  beats  from  130  to  150  times  a  minute.     It  is  slightly  more  frequent 


Fig.  170. 


-Internal  Ballotement  at  the  Sixth  Month. 

Posture. 


Patient  is  in  the  Reclining 


in  small  than  in  large  children.  Attempts  have  been  made  from  this  to  pre- 
dict the  sex  of  the  child,  since  males  are  usually  larger  than  females.  When 
the  sounds  are  distinctly  heard,  but  the  uterus  is  too  small  to  contain  a  fetus 
old  enough  to  make  them,  there  is  a  strong  indication  of  extrauterine  pregnancy. 
(4)  Ballottement. — In  the  latter  part  of  the  fourth  month,  or  the  first 
part  of  the  fifth,  ballottement  may  be  practised.  The  preferable  position  for 
the  patient  is  reclining,  midway  between  standing  and  sitting,  although  either 
of  the  latter  positions  may  be  assumed  (Fig.  170).  Ballottement  is  the  earliest 
of  the  positive  signs,  as  it  may  be  obtained  from  the  fourteenth  or  fifteenth 
week  till  within  six  or  eight  weeks  of  delivery.  In  practising  ballottement 
the  examining  finger  is  introduced  into  the  vagina  and   suddenly  pushed  up 


THE   DIAGNOSIS  OF   PREGNANCY.  129 

against  the  lower  portion  of  the  uterus.  The  impulse  thus  generated  is  trans- 
mitted to  the  fetus,  which  bounds  upward  and  then  falls  back  upon  the  ex- 
amining finger  (Fig.  170).  This  is  a  physical  sign  of  pregnancy  which,  when 
clearly  made  out,  is  infallible;  for  although  an  antefiexed  fundus,  or  a  calculus 
in  the  bladder,  or  some  other  pathological  conditions,  may  give  rise  to  very 
similar  sensations,  still,  in  such  cases,  no  other  signs  of  pregnancy  will  be  present. 
Before  the  end  of  the  fourth  month  the  fetus  is  too  small  to  respond  to  the 
digital  impulse,  and  after  the  seventh  month  the  child  is  relatively  too  large, 
so  nearly  filling  the  uterine  cavity  that  it  cannot  be  moved  about  as  freely  as 
formerlv.     In  multiple  pregnancies,  and  in  deficiency  of  the  liquor  amnii,  the 


»-:«»(' 


%k       \ 


Fig.  171. — Auscultation  op  the  Fetal  Heart  with  the  Phonendoscope.  Method  of 
raising  the  fundus  of  the  uterus  upward  and  forward  so  as  to  bring  the  uterine  walls 
close  to  the  abdominal  parietes  and  thus  intensify  the  fetal  heart-sounds. — {From  a 

photograph  at  the  Emergency  Hospital.) 

sign  will  be  absent  for  the  same  reason.  Neither  shoulder  nor  breech  presenta- 
tions, as  a  rule,  respond  to  this  test. 

(5)  Umbilical  Murmur,  or  Souffle,  consists  of  a  slight  blowing  murmur, 
synchronous  with  the  fetal  heart  sounds,  and  most  distinctly  heard  in  their 
vicinity.  The  sound  can  be  detected  in  about  15  per  cent,  of  all  the  cases  of 
pregnancy,  and  is  thought  to  be  due  to  pressure  upon  the  umbilical  cord,  from 
its  coiling,  or  from  some  form  of  compression.  Its  position  varies  with  the 
presentation  of  the  child.     Its  practical  value  is  nil. 

6.  Sympathetic  and  Reflex. — (i)  Nausea  and  Vomiting;  Morning  Sick- 
ness. (See  Digestive  System,  page  115.)  (2)  Sympathetic  Disturbances 
OF  THE  Nervous  System,  such  as  changes  in  disposition  and  taste,  have  no 
9 


130  PHYSIOLOGICAL   PREGNANCY. 

value  in  the  diagnosis  of  pregnancy  and  have  been  described  under  The  Phe- 
nomena of  Pregnancy. 

7.  Pressure  and  Congestion. — The  neighboring  organs  are  disturbed  by  the 
growth  and  development  of  the  uterus,  these  disorders  depending  partly  upon 
hyperemia  and  partly  on  mechanical  pressure,  (i)  Bladder:  The  bladder 
becomes  irritable;  during  early  pregnancy  frequerit  micturition,  incontinence, 
and  vesical  tenesmus  are  common  symptoms.  In  a  woman  previously  free 
from  vesical  irritation,  this  symptom,  in  conjunction  with  cessation  of  men- 
struation, we  have  frequently  found  most  valuable,  and  we  would  class  it  as 
a  probable  sign.  In  our  experience,  persistent  vesical  irritation  is  the  most 
valuable  of  the  very  early  symptoms.  (See  Bladder,  page  112.)  (2)  Rectum: 
In  the  latter  months  fecal  accumulations  in  the  lower  bowel  cause  much  irrita- 
tion and  discomfort.  (3)  Lower  Extremities:  Sciatica,  oedema,  and  varicosi- 
ties are  frequently  observed  as  the  result  of  pressure. 

8.  Cutaneous. — Pigmentation  of  the  forehead  and  cheeks,  in  the  form  of  dark 
brown  patches  termed  chloasmata,  or  blotches,  is  found  in  some  pregnant  women, 
especially  brunettes.  These  patches,  as  well  as  the  dark  circles  about  the  eyes, 
are  most  uncertain  signs,  and  are  found  occasionally  during  menstruation  and 
in  ovarian  and  uterine  disease.  Pigmentation  and  striae  of  the  breasts  and 
abdomen  have  already  been  classified  under  Mammary  and  Abdominal  Signs. 

9.  Individual  and  Subjective. — A  woman  who  has  borne  many  children 
is  often  better  able  to  tell  when  she  has  conceived  than  is  the  most  skilful  diag- 
nostician. Under  these  circumstances  the  truth  is  reached  by  individual  or 
idiosyncratic  phenomena.  Dismissing  as  entirely  untrustworthy  the  existence 
of  peculiar  sensations  during  the  impregnating  coitus,  there  can  be  no  doubt 
that  individual  signs  may  appear  within  a  few  days  after  conception.  One 
woman  under  these  circumstances  experiences  a  characteristic  vertigo,  another 
nose-bleed,  a  third  pruritus  vulvas,  a  fourth  swelling  and  tenderness  in  the  veins 
of  the  lower  extremities  (in  cases  of  past  puerperal  phlebitis).  The  various 
sensations  experienced  have  an  individuality  which  is  never  noticed  on  any 
other  occasion. 

SUMMARY   OF   THE    DIAGNOSTIC   SIGNS    OF    PREGNANCY. 

The  symptoms  and  signs  of  pregnancy  may  be  divided  into  three  classes: 
(I)  Doubtful;  (II)  probable;  (III)  certain.  The  first  may  occur  in  the  male. 
The  second  have  to  do  only  with  the  genitals  of  the  woman.  The  third  are 
produced  only  by  the  presence  of  the  fetus.  (I)  To  this  class  belong  all  those 
signs  dependent  partly  on  pressure,  and  partly  on  blood  changes,  or  alterations 
in  nervous  activity.  These  are  nausea,  vomiting,  fainting,  varicosities,  oedema, 
headache,  toothache,  and  backache,  also  pigmentation  of  the  skin,  frequent 
micturition,  and  "longings"  or  "cravings."  These  signs  are  almost  valueless; 
save  in  cases  of  multiparas,  who,  never  having  suffered  otherwise  from  any  of 
these  symptoms,  have  noted  a  certain  syndrome  in  every  pregnancy.  In  some 
instances  nausea,  vomiting,  and  depressed  spirits  have  occurred  almost  im- 
mediately after  a  fruitful  coitus,  so  that  the  patient  was  aware  of  her  condition 
before  the  cessation  of  the  menses.  (II)  The  next  group  proceeding  from  the 
female  genitalia  is  of  more  importance  and  comprises:  (a)  cessation  of  the  menses. 
(b)  The  changes  in  the  color  of  the  vulva,  vagina,  and  uterus;  the  palpable 
pulsation  in  the  vaginal  fomices ;  the  increasing  size  of  the  uterus ;  the  rounding 
of  the  external  os;  and  the  softening,  elasticity,  and  thinning  of  the  uterus  just 
above  the  insertion  of  the  sacro-uterine  ligaments,     (c)   The  uterine  souffle. 


THE   DIAGNOSIS   OF   PREGNANCY.  131 

(d)  Breast  changes,     (e)  The  striae  and  umbiHcal  changes.     (Ill)  The  certain 
signs  are:  (a)  Mapping  out  of  the  fetus.     (6)  Fetal  heart  sounds,     (c)  Move- 
ment of  the  child  as  felt  by  -the  examiner,     (d)  Umbilical  murmur. 
To  recapitulate: 

I.  The  Positive  or  Certain  Signs  are  :  (i)  Mapping  out  the  whole  or  parts  of 
the  fetus  by  palpation.  (2)  The  fetal  heart  sounds.  (3)  Movements  of  the 
fetus,  active  or  passive;  to  be  regarded  only  when  confirmed  by  an  experienced 
observer.  (4)  Vaginal  and  abdominal  ballottement.  (5)  The  umbilical  or  funic 
murmur,  in  the  10  or  15  per  cent,  of  cases  in  which  it  is  present,  is  also  a  certain 
sign. 

II.  The  Probable  Signs  are:  (i)  The  progressive  enlargement  of  the  uterus 
and  its  characteristic  alterations  in  shape.  (2)  The  compressibility  of  the 
lower  uterine  segment — Hegar's  sign.  (3)  Intermittent  uterine  contractions — 
Braxton  Hicks's  sign.  (4)  Changes  in  consistency  of  enlarging  uterus.  (5) 
Changes  in  consistency  and  color  of  vagina  and  cervix.  (6)  Uterine  murmur. 
(7)  Cessation  of  menstruation.  (8)  Mammary  signs —enlargement  of  breasts 
and  Montgomery's  tubercles.     (9)  Pigmentation  and  secretion. 

III.  The  Uncertain  or  Doubtful  Signs  are:  (i)  Changes  in  size  and  shape 
of  abdomen  as  well  as  pigmentation,  strias,  fluctuation  and  changes  in  the  per- 
cussion note.  (2)  Sympathetic  and  reflex  disturbances — nausea,  vomiting,  alter- 
ations in  taste  and  disposition.  (3)  Pressure  and  congestive  signs — irritable 
bladder  or  rectum,  pain,  and  oedema  in  lower  extremities.  (4)  Cutaneous  signs — 
chloasmata  on  the  forehead  and  cheeks  and  dark  circles  under  the  eyes.  Pigmen- 
tation and  striae  of  the  abdomen  and  breasts  have  already  been  classified. 

The  signs  of  pregnancy  may  be  classified,  finally,  according  to  the  time  at 
which  they  appear.  First  month  :  The  abdominal  changes  begin  to  appear. 
There  is  cessation  of  menstruation.  It  is  early  for  the  manifestation  of  morning 
sickness,  and  for  changes  in  the  breasts,  though  they  may  take  place.  The 
cervix  begins  to  soften  from  the  very  first.  Second  month :  Hegar's  sign  may 
now  be  obtained.  There  is  pulsation  in  the  vaginal  vault.  This  month  is 
the  ordinary  time  for  the  beginning  of  mammary  and  gastric  changes.  Depres- 
sion of  the  umbilicus  persists,  and  the  uterus  sinks,  while  the  abdomen  is  flat. 
Third  month  :  The  umbilicus  is  still  depressed,  and  the  uterus  sunken  till  the  end 
of  this  month,  when  it  begins  to  rise.  The  softening  of  the  cervix  increases 
in  extent.  Gastric  ^nd  mammary  changes  continue.  Fourth  month :  The 
uterus  begins  to  rise,  consequently  the  depression  at  the  navel  commences  to 
fill  out,  and  the  abdomen  to  become  prominent.  The  breast  changes  increase, 
but  as  a  rule  the  gastric  disturbances  cease.  At  the  end  of  the  month 
the  heart  sounds  may  rarely  be  heard.  The  uterine  murmur  is  present.  The 
patient  sometimes  feels  quickening,  and  the  examiner  may  detect  fetal  move- 
ments, as  well  as  uterine  contractions.  Fifth  month :  Normally  at  this  time 
the  gastric  disturbances  have  entirely  ceased,  and  the  appetite  and  digestion 
are  excellent.  The  abdomen  is  plainly  increased  in  size,  and  frequently  quick- 
ening is  felt.  The  mammary  changes  continue,  with  the  appearance  of  the 
secondary  areola.  Ballottement  readily  reveals  the  presence  of  the  fetus  and 
heart  sounds  are  plainly  audible.  Sixth  month  :  The  sounds  and  motions  of 
pregnancy  are  all  evident.  In  multigravidae  the  external  os  is  patulous,  ad- 
mitting a  finger-tip.  The  fundus  is  about  at  the  level  of  the  navel.  Cutaneous 
striae  develop.  Seventh  month  :  The  external  os  may  now,  even  in  primiparag, 
admit  the  finger-tip.  The  cervix  is  more  elevated  in  the  vagina.  The  fundus 
is  two  inches  above  the  umbilicus.  Ballottement  is  still  obtainable.  The  vaginal 
part  of  the  cervix  is  apparently  shortened  one-half.     Cutaneous  striae  continue 


132 


PHYSIOLOGICAL   PREGNANCY. 


to  develop.  Eighth  month-:  Ballottement  is  hardly  obtainable.  The  fundus 
is  halfway  between  the  umbilicus  and  the  ensiforai  cartilage.  The  abdomen 
is  much  enlarged,  and  is  pear-shaped.  The  umbilicus  may  begin  to  pout  at  the 
end  of  this  month,  and  in  multigravidae  milk  may  be  secreted.  Fetal  parts  are 
easily  palpable.  Ninth  month  :  Ballottement  is  no  longer  obtainable,  although 
the  other  physical  signs  are  all  more  marked.  The  fundus,  at  the  end  of 
this  month,  is  almost  at  the  ensiform  cartilage.  The  cervix  still  seems  shorter. 
The  OS  is  very  patulous,  especially  in  multigravidae.  The  umbilicus  protrudes. 
Tenth  month  :  The  physical  signs  are  distinct.  At  the  middle  of  this  month 
the  fundus  is  at  its  greatest  height.  It  settles  down  in  the  last  two  weeks, 
thereby  lessening  the  pressure  symptoms,  while  the  os  also  sinks  and  the  um- 
bilical prominence  decreases.  The  patient  feels  lighter  and  more  comfortable. 
There  may,  however,  be  difficulty  in  locomotion  and  oedema  of  the  genitals 
and  legs.  The  vertex  is  usually  engaged  in  the  pelvis  in  primigravidae  and  at 
the  inlet  in  multigravidae.  The  cervical  canal  in  primigravidae  shortens  and 
disappears  just  before  or  at  term,  and  in  multigravidae  several  days  or  even 
weeks  before  labor. 


IV.   THE    DIFFERENTIAL  DIAGNOSIS    OF   PREGNANCY. 

I.  Non-pregnant  Enlargements  of  the  Uterus. — (i)  Hematometra,  usually 
due  to  retained  menses,  is  a  rare  condition;  non-appearance  of  menstruation 
occurs  with  imperforate  hymen,  or  obstruction  in  the  cervical  canal,  and  the 


Fig.  172. — -Hematometra.  A  Non-preg- 
nant Enlargement  of  the  Uterus. — 
(Montgomery.) 


Fig.  173. — Hematocolpometra.  A  Non- 
pregnant Enlargement  of  the  Uterus. 
— {MoTitgomery.) 


tumor  develops  slowly  with  periodic  increase  in  size  (Figs.  172  and  173).  (2) 
Hydrometra  may  be  due  to  the  closure  of  the  external  or  internal  os,  or  both, 
with  catarrhal  discharge  from  the  mucous  membrane,  which  by  its  accumulation 
causes  enlargement  of  the  uterus.     At  times  a  watery  fluid  accumulates  in  the 


THE   DIFFERENTIAL   DIAGNOSIS   OF  PREGNANCY. 


133 


Fig.  174. — Diffuse  Interstitial  Myomata. 
A  Non-pregnant  Enlargement  of  the 
Uterus. — (Alontgomery.) 


uterus;  this  condition  is  rare,  and  is  very  seldom  seen  before  the  menopause. 

(3)  Physometra  is  due  to  the  generation  and  retention  of  gas  in  the  uterus.  This 
is,  indeed,  a  tympanites  of  the  letter.  When  the  uterus  has  reached  such  a  size 
that  it  may  be  percussed,  resonance  is 

obtained.  Sometimes  foul-smelHng 
gas  escapes  per  vaginam,  and  when 
the  uterus  is  raised  its  weight  does 
not  correspond  with  its  size,  the 
organ  being  much  hghter  than  would 
be    supposed    from    its    appearance. 

(4)  Pyometra  consists  in  the  accumula- 
tion of  pus  in  the  uterine  cavity. 
Hematometra,  hydrometra,  physo- 
metra, and  pyometra  are  very  rare 
conditions,  while  pregnancy  is  very 
common.  The  first  three  conditions 
consist  in  the  distention  of  the  uterus 
by  blood  or  other  liquid,  or  by  gas 
of  some  sort.  The  atresia  which  pro- 
duces these  conditions  may  be  con- 
genital or  acquired.  There  is  no  his- 
tory of  exposure  to  impregnation,  as 
there  is  in  pregnancy ;  the  menses  are 
absent,  as  a  result  of  imperforate  hy- 
men, or  of  traumatic  or  inflammatory 

occlusion  of  the  cervix.  In  pregnancy  there  is  the  normal  history  of  menstru- 
ation with  the  sudden  cessation  of  its  appearance.     In  these  abnormal  conditions 

there  is  a  history  of  a  slowly 
developing  tumor,  with  sud- 
den and  periodic  enlarge- 
ment, followed  by  slight  de- 
crease in  size.  These  periods 
correspond  to  the  menstrual 
epochs  and  are  characterized 
by  great  pain.  The  duration 
greatly  exceeds  that  of  preg- 
nancy. By  physical  exam- 
ination in  pregnancy  the 
vagina  is  found  congested 
and  softened,  while  in  these 
diseased  conditions  it  is  gen- 
erally discovered  to  be  ab- 
normal in  some  respect. 
The  mammary  changes  in 
pregnancy  are  suggestive. 
(5)  Chronic  Metritis  gives 
the  uterus  a  firmer  resist- 
ance than  is  imparted  by 
pregnancy;  Hegar's  sign  is 
not  present,  nor  is  the  characteristic  "  pot-bellied  "  shape  of  the  uterus  of  preg- 
nancy. Amenorrhea  is  often  present,  and  a  purulent  secretion  frequently  co- 
exists.    (6)  Subinvolution  is  generally  accompanied  by  pain  in  the   dorsal  or 


Fig.  175. — Large  Myomata  op  Anterior  and  Pos- 
terior Uterine  Walls.  A  Nonpregnant  Enlarge- 
ment of  the  Uterus. — {Montgomery.) 


134 


PHYSIOLOGICAL  PREGNANCY. 


ovarian  regions,  with  tenderness  of  the  uterus  itself.  There  is  a  history  of  very- 
abnormal  menstruation,  together  with  a  bloody,  muco-purulent  leucorrhea. 
There  is  no  increase  in  the  size  of  the  uterus,  nor  are  there  any  signs  of  pregnancy. 
Locomotion  is  difficult,  and  the  patient  may  have  amenorrhea  from  anemia  or 
lactation.  (7)  Myoma  and  Fibroma:  These  tumors  are  usually  irregular,  firm, 
dense,  and  not  necessarily  in  the  median  line.  Menstruation  is  irregular  and  pro- 
fuse, and  the  uterine  evidences  of  pregnancy  are  mostly  absent,  especially  the 
Hegar  and  Braxton  Hicks  signs;  on  the  other  hand,  asymmetry  and  the  uterine 
souffle  are  sometimes  demonstrable.  There  is,  further,  a  history  of  slow  and 
protracted  growth,  which  may  extend  over  months  or  even  years  (Figs.  174, 
175,  176,  and  177).  (8)  Congestive 
Hypertrophy  of   the    Uteriis:    This 

affection  is   not  infrequently  mis-  -=-—  ._      v     .       \ 

taken    for    pregnancy,     especially 
when  accompanied  by  amenorrhea.  / 

However,    in    this     condition    the 


Fig.  176. — Local  Interstitial  Myo- 
MATA.  A  Non-pregnant  Enlarge- 
ment OF  the  Uterus. —  (Montgomery.) 


Fig.  177. — Myoma  of  the  Body  and  Can- 
cer OF  THE  Cervix.  A  Non-pregnant 
Enlargement  of  the  Uterus. — {Mont- 
gomery.) 


uterus  is  apt  to  be  tender  and  the  seat  of  considerable  pain.     Time  will  give 
the  correct  diagnosis. 

2.  Uterus  Normal  in  Size  with  Extrauterine  Enlargements. — (i)  Abdominal 
Fat:  This  condition  becomes  more  common  as  age  increases.  It  usually  simu- 
lates pregnancy  in  the  very  young  and  anemic.  Menstruation  in  the  obese  is  often 
irregular  and  scanty.  The  cervix  is  neither  enlarged  nor  softened.  A  uterus 
of  normal  size  may  be  recognized  by  the  vaginal  or  rectal  touch,  and  if  the 
abdominal  fat  can  be  pushed  aside  a  tympanitic  resonance  may  be  obtained 
over  the  umbilical  region.  (2)  Distended  Bladder:  The  duration  of  this 
condition  is  relatively  brief.  There  are  external  discomfort  and  dribbling|^of 
urine.  The  position,  shape,  and  resistance  resemble  those  of  the  pregnant  uterus. 
In  retroflexion  of  the  uterus  the  distended  bladder  is  often  mistaken  for  the 
uterus.      Catheterization  of  the  bladder  will  at   once  clear   up  the   diagnosis. 


THE   DIFFERENTIAL  DIAGNOSIS   OF  PREGNANCY. 


135 


(3)  Fecal  Accumulation  sometimes  produces  enlargement  of  the  abdomen. 
Catharsis  and  enemata  will  remove  this  condition.  (4)  Ovarian  Tumor  (Cys- 
toma) (Fig.  178):  In  this  condition  most  of  the  probable  signs  of  pregnancy 
are  absent.  The  abdominal  tumor  is  soft,  fluctuating,  and  usually  unilateral. 
A  normal  uterus  should  be  made  out  by  direct  examination.  There  is  also  a 
history  of  a  slowly  growing  unilateral  tumor,  with  the  presence  of  the  cachexia 
and  facies  which  accompany  ovarian  tumors.  There  may,  however,  be  co- 
existence of  the  two  conditions,  which  makes  the  diagnosis  difficult.  The  two 
tumors  will  then  be  of  different  consistence,  and  may  have  a  groove  between 
them.  Vaginal  examination  will  reveal  enlargement  of  the  uterus,  while 
there  are  also  present  the  signs  of  ovarian  cyst.  There  should  be  further  evi- 
dences of  pregnancy.  Aspiration  of  the  ovarian  tumor  is  no  longer  practised, 
as  in   this    procedure  there  is  nothing  to  be  gained  in  making  the  diagnosis. 

(5)  Ascites:  In  this  condition  the  certain  and  probable  signs  of  pregnancy  are 
all  absent  and  the  cervix  and  body  of  the  uterus  possess  normal  characters. 
The  abdomen,  flattened  in  front  and  bulging  at  the  sides,  exhibits  fluctuation. 
By  changing  the  woman's  position  the  horizontal  limits  of  percussion-reso- 
nance change.     In  the  dorsal 

position  there  is  dullness  in 
the  flanks  on  percussion.  The 
condition  upon  which  the  as- 
cites depends  may  be  in  evi- 
dence (cirrhosis  of  the  liver, 
tuberculous  peritonitis,  etc.). 

(6)  Pelvic  Hematocele :  This 
condition,  which  usually  oc- 
curs in  the  broad  ligament, 
could  hardly  be  mistaken  for 
pregnancy.  (7)  Pelvic  Exu- 
dations: The  uterus  may  be 
surrounded  by  pelvic  exudate, 
the  whole  representing  an  ap- 
parently homogeneous  swell- 
ing. (8)  Retroversion  and  Re- 
troflexion: These  conditions  have  been  mistaken  for  pregnancy  at  times,  since 
they  frequently  cause  hypertrophy  of  the  uterus,  and  irregularities  or  cessation 
of  the  menses.  The  history  must  be  carefully  investigated.  Vaginal  examina- 
tion generally  discloses  an  anteposed  cervix  of  firm  consistence.  The  tumor  will 
also  be  found  situated  in  Douglas's  cul-de-sac.  Very  careful  examinations,  re- 
peated at  short  intervals,  will  reveal  the  true  nature  of  the  case.  Sometimes 
several  months  will  be  required  to  make  the  diagnosis  certain.  The  greatest  diffi- 
culty will  be  found  in  those  cases  in  which  the  fundus  has  reached  the  superior 
margin  of  the  symphysis,  or  a  little  higher,  before  the  convincing  signs  of  preg- 
nancy are  present,  and  when  the  fetus  is  dead.  Time  is  often  required  for  clearing 
up  this  diagnosis.  Large  tumors  should  generally  offer  little  difficulty,  but  the 
possibility  of  the  coexistence  of  pregnancy  and  a  tumor  should  always  be  remem- 
bered. (9)  Tympanites  :  In  this  condition  the  whole  abdominal  surface  will 
give  a  clear  note  of  percussion;  the  signs  of  pregnancy,  both  subjective  and 
objective,  are  all  wanting.  Tympanites  and  pregnancy  may  coexist,  however. 
Tympanites  may  be  excluded  by  feeling  the  spinal  column  through  the  abdomi- 
nal wall.  This  may  be  accomplished  by  firmly  pressing  the  hands,  one  on  the 
other,  against  the  abdomen,  while  the  patient   draws  deep  breaths.     The  pres- 


FiG.  178. — Intraligamentous  Myoma.     Uterus  Nor- 
mal IN  Size  with  a  Pelvic  Tvmor.— (Montgomery.) 


136 


PHYSIOLOGICAL  PREGNANCY. 


sure  should  be  especially  firm  during  expiration.  In  this  way  the  absence  of  a 
gravid  uterus  may  be  proved.  The  enlargement  also  varies  in  the  two  condi- 
tions: in  pregnancy  it  is  chiefly  antero-posterior  in  the  first  months,  while  in 
tympanites  it  is  uniform  in  all  directions.  There  should  be  no  resonance  over 
the  uterus,  since  the  intestines,  as  a  rule,  are  above  and  behind  the  organ.  As 
before  noted,  however,  the  intestines  may  be  forced  over  the  anterior  face  of 
the  uterus  from  gaseous  distention.  (lo)  Distended  Tubes,  perhaps  adherent 
to  the  uterus,  might  possibly  simulate  pregnancy.  In  this  case  they  will 
move  with  the  cervix,  (ii)  Encysted  Peritonitis  and  (12)  Ectopic  Gestation 
may  sometimes  cause  confusion.     (13)  Enlarged  Abdominal  Organs  may  suggest 

pregnancy;  they,  however,  increase 
from  above  downward.  In  case  of 
wandering  spleen  or  kidney,  the  or- 
gan can  be  pushed  upward.  Reso- 
nance may  be  obtained  below  the 
limit  of  dullness  and  will  show  the 
cause  of  enlargement.  Encysted 
dropsy  may  be  met  with,  but  very 
infrequently.  In  malignant  growths 
of  the  omentum  and  mesentery  there 
are  irregularity  and  fixation.  If  the 
growths  are  extensive  and  have  ex- 
isted for  some  time,  there  is  apt  to  be 
cachexia. 

3.  Pregnancy  with  Extrauterine 
Enlargements. — The  physician  must 
be  on  his  guard  against  a  combination 
of  these  conditions;  for  example,  in- 
trauterine pregnancy  and  ectopic  ges- 
tation may  exist  together;  or  one  of 
these  conditions  with  an  ovarian 
tumor;  also  in  intrauterine  pregnancy 
the  uterus,  from  retroflexion,  or  re- 
troversion, or  both,  may  give  the  ap- 
pearance of  a  tumor  in  Douglas's  cul- 
de-sac.  Abdominal  enlargement  from 
pathogenic  conditions  sometimes  oc- 
curs in  combination  with  pregnancy. 
In  these  cases  the  latter  condition  is 
very  apt  to  be  overlooked,  while  the 
former  is  the  only  one  recognized. 
In  certain  cases  the  pathological  conditions  may  be  removed,  and  then  the 
pregnancy  will  become  apparent.  The  abdominal  walls  also  may  contain  an 
undue  amount  of  fat,  which  will  tend  to  obscure  the  gestation,  (i)  Ascites  may 
coexist  with  pregnancy  and  in  various  clinical  forms,  due  respectively  to  (a) 
tuberculous  peritonitis,  which  may  develop  slowly  side  by  side  with  gestation; 
(6)  some  obstruction  of  the  portal  circulation  (cirrhosis  of  the  liver,  pylephlebitis) ; 
(c)  obstruction  of  the  circulation  of  lymph;  and,  finally,  {d)  pregnancy  itself, 
which  may  produce  ascites  as  a  result  of  a  pathological  condition  which  affects 
the  maternal  peritoneum  and  fetal  amnion.  (2)  Ectopic  pregnancy  may  be 
associated  with  normal  uterine  gestation,  and  the  presence  of  the  latter  furnishes 
a  contraindication  to  the  operative  treatment  of  the  former,  although  in  cases 


I-  \ 


Fig.  179. — An  Ovarian  Cyst  Behind  and 
TO  One-  Side  of  a  Pregnant  Uterus. 
Pregnancy  with  a  Pelvic  Tumor. — 
{Montgomery.) 


THE  DIFFERENTIAL   DIAGNOSIS   OF  PREGNANCY. 


137 


of  this  description  both  fetuses  have  been  dehvered  ahve  by  laparotomy.  As  a 
rule,  the  embryos  have  the  same  degree  of  development.  Normal  pregnancy 
may  also  be  associated  with  a  past  extrauterine  gestation.  (3)  There  may  also 
be  coexistence  of  uterine  and  cornual  pregnancy ;  this  latter  condition  often  so 
nearly  resembles  ectopic  gestation  that  it  cannot  always  be  differentiated  from 
it.  (4)  Persistent  distention  of  the  bladder  may  sometimes  obscure  beginning 
pregnancy.  It  would  be  almost  impossible  to  confuse  the  (5)  tumor  of  appen- 
dicitis with  beginning  gestation.  (6)  Ovarian  tumors  not  infrequently  com- 
plicate pregnancy;  this  combination  may  give  rise  to  much  danger  to  the 
mother,  for  it  will  be  almost  impossible  for  the  abdomen  to  accommodate  both 
of  these  tumors,  growing  simultaneously  (Fig.  179).  Sometimes  the  tumor  is 
subjected  to  such  pressure  that  it  may  burst  and  discharge  its  contents  into 
the  peritoneal  cavity;  or  it  may  give  rise  to  a  slow  inflammatory  process,  causing 
much  exhaustion,  and  finally  terminating  fatally.  Several  lines  of  treatment 
are  suggested — ovariotomy,  or  induced  labor.  (7)  At  times  small  tumors 
develop,  which  may  gradu- 
ally rise  above  the  brim.  In 
this  case,  if  the  tumor  is  not 
behind  the  uterus,  it  may  be 
distinguished  from  that  or- 
gan. On  the  other  hand, 
the  abdomen  may  be  so  dis- 
tended by  the  presence  of 
the  gravid  uterus  and  the 
tumor  that  hydramnios  or 
twins  may  be  suspected. 
(8)  Pyosalpinx  or  hydro- 
salpinx may  also  complicate 
pregnancy.  (9)  Other  tu- 
mors of  the  soft  parts  have 
at  times  to  be  considered; 
e.  g.,  those  of  the  broad  liga- 
ments, tubal  and  other  swell- 
ings. (10)  Ventral  hernia 
and  pendulous  abdomen 
must  be  distinguished.  (11) 
A  large  floating  kidney,  or 

displaced  spleen  or  liver,  or  tumors  of  any  of  the  abdominal  viscera,  such  as 
hydatids  of  the  liver,  or  carcinomatous  tumors,  may  be  found  in  conjunction 
with  pregnancy,  as  has  been  stated. 

In  some  conditions  it  is  possible  to  remove  the  trouble  which  obscures  the 
pregnancy,  and  then  the  latter  stands  out  clearly.  However,  the  best  way  of 
making  a  true  and  positive  diagnosis  of  the  pregnant  state  is  to  make  several 
examinations,  and  to  wait  until  undeniable  proofs  of  gestation  are  present. 
There  is  one  differential  point  of  great  value  in  the  diagnosis  of  pregnancy :  after 
the  sixth  month  it  is  the  only  abdominal  tumor  which  presents  the  condition  of 
a  movable  solid  mass  in  a  liquid. 

From  a  medico-legal  standpoint  the  diagnosis  between  a  muciparous  and 
puerperal  uterus,  and  between  a  primigravida  and  multigravida,  sometimes 
becomes  important.  Multiparous  Uterus:  Cavity  2^  inches  (6.5  cm.),  trian- 
gular; cervix  small,  cartilaginous,  and  same  length  as  body;  external  os  trans- 
verse,   and    edges    smooth;  uterus    anteflexed;  external   os    closed.     Puerperal 


Fig.  180. — Pregnancy  Complicated  by  Myoma  of  the 
Anterior  Uterine  Wall.  Pregnancy  with  a  Pel- 
vic Tumor. — {Montgomery.) 


138  PHYSIOLOGICAL   PREGNANCY. 

Uterus:  Cavity  3  inches  (7.5  cm.),  or  over,  oval;  cervix  large,  soft,  larger  than 
body;  irregular  external  os,  with  roughened  edges;  axis  of  uterus  straight, 
retrodisplaced;  external  os  patulous.  Primi gravida:  Fourchette  present;  peri- 
neum intact;  labia  in  apposition;  granular  condition  of  vagina  present;  cervix 
long,  conical,  or  closed;  abdomen  tense;  pinkish  strias,  late  in  pregnancy;  breasts 
full,  firm,  sensitive;  nipples  undeveloped;  strias  usually  absent  from  breasts. 
MuUigravida:  Fourchette  absent;  perineum  relaxed  or  torn;  labia  frequently 
patulous;  granular  condition  of  vagina  absent;  cervix  short  and  open;  abdomen 
relaxed;  white  striae,  from  beginning  of  pregnancy;  breasts  relaxed;  nipples 
large  and  developed;  striae  frequently  present  on  breasts. 


V.  FEIGNED  PREGNANCY,  PSEUDOCYESIS. 

Pregnancy,  for  various  reasons,  may  be  feigned  or  simulated.  Suits  are 
frequently  brought  for  damages,  or  to  compel  marriage,  and  it  then  becomes 
the  duty  of  the  physician  to  render  a  decision  in  the  case.  The  pregnancy 
may  be  purposely  feigned  or  simulated,  or  the  woman  in  question  may  really 


J 


Fig.  iSr. — Author's  Case  of  Feigned  or  False  Pregnancy  (Pseudocyesis)  at  the 
Thirty-sixth  Week  (?).  A  bimanual  exartiination  revealed  a  uterus  normal  in  size 
and  position. — {From  a  tracing.) 

believe  herself  to  be  pregnant.  The  latter  condition  is  one  well  recognized 
in  obstetric  medicine;  and  constitutes  what  authorities  variously  term  false, 
spurious,  or  nervous  pregnancy,  or  pseudocyesis.  In  cases  of  feigned  or  simu- 
lated pregnancy,  a  physical  examination  removes  all  doubt;  for  although  the 
woman  may  simulate  many  of  the  doubtful  signs  of  pregnancy  in  her  attempt 


UNCONSCIOUS   PREGNANCY.  139 

to  deceive,  yet  an  examination  reveals  none  of  the  probable  or  sure  signs,  and 
the  uterus  is  found  of  normal  size  (Fig.  i8i).  Pseudocyesis  is  observed  in 
women  who  are  advanced  .in  .years;  in  those  who  have  an  intense  desire  to 
become  pregnant;  in  women  who  marry  late  in  life,  and  are  anxious  to  prove 
their  power  of  reproduction.  Most  frequently  we  observe  the  condition  in  a 
woman  who  is  approaching  the  menopause,  when  her  menstrual  flow  has  become 
scanty,  or  has  ceased  outright  for  a  time;  a  deposit  of  fat  takes  place  in  her 
anterior  abdominal  walls,  and  her  intestines  become  distended  by  flatulence. 
In  such  a  case  many  of  the  doubtful  and  some  of  the  probable  signs  of  pregnancy 
are  present.  For  example,  menstruation  may  cease;  the  mammary  signs  of 
gestation  appear,  even  to  the  secretion  of  colostrum  or  milk;  the  abdomen 
becomes  progressively  more  prominent;  the  woman  assures  her  physician  that 
fetal  movements  (quickening)  are  present;  and  this  may  end  in  what  is  termed 
spurious  labor.  (See  Part  IV.)  The  diagnosis  of  the  condition  is  not  difflcult. 
Above  all,  the  physician  should  be  on  his  guard  against  accepting  any  statements 
the  patient  may  offer  in  regard  to  her  condition;  and  in  expressing  an  opinion, 
he  should  rely  upon  the  exclusion  of  the  probable  and  certain  signs  of  gestation, 
which  he  does  by  a  careful  physical  examination  of  the  woman,  preferably 
with  the  aid  of  anesthesia. 

In  the  Robert  Ray  Hamilton  case,  which  occurred  in  New  York  in  the  latter  part  of 
1888,  Mr.  Hamilton's  mistress  represented  to  him  that  she  was  pregnant  by  him.  He  be- 
lieved this  to  be  the  case,  and  gave  her  considerable  sums  of  money  to  enable  her  to  go  into 
the  country  to  be  confined.  She  went  away,  remained  a  few  months,  and  upon  her  retiim 
produced  a  child  which  she  stated  was  the  child  bom  at  her  alleged  confinement.  He  fully 
believed  her  story  and  accepted  the  child  as  his  own.  It  appears  from  the  police  memoranda 
that  several  children  were  bought  from  midwives  for  sums  of  from  ten  to  fifteen  dollars,  and 
that  two  of  these  died  while  acting  their  parts  as  supposititious  children.  Owing  to  a  quar- 
rel between  nurses,  the  fraud  was  finally  discovered,  and  the  woman  and  her  accomplices 
were  indicted  for  obtaining  money  under  false  pretenses.  The  indictment  never  came  to 
trial.* 


VI.  UNCONSCIOUS  PREGNANCY. 

It  is  not  only  possible,  but  quite  common,  for  women  to  become  pregnant 
and  remain  so  for  some  time  before  they  become  aware  of  their  condition.  This 
applies  more  particularly,  if  not  exclusively,  to  those  who  are  married.  In  the 
unmarried,  in  spite  of  their  serious  protestations  of  entire  ignorance  of  everything 
concerning  the  matter  in  question,  unconscious  impregnation  and  pregnancy 
is  a  rare  condition.  Many  cases  may  be  furnished  of  married  women,  espe- 
cially those  childless  for  a  number  of  years,  who  finally  really  do  become  preg- 
nant, and  then  refuse  to  believe  the  medical  attendant  when  assured  that  such 
is  the  case,  believing  their  altered  condition  to  be  due  to  some  disease.  "When 
a  woman  is  impregnated  in  a  lethargic  state,  it  is  unlikely  that  she  should  go 
beyond  the  sixth  month  without  being  fully  aware  of  her  pregnancy ;  and  if  her 
motives  were  innocent,  she  would  undoubtedly  make  some  communication 
to  her  friends"  (Taylor).  It  must  be  borne  in  mind,  however,  that  it  is  possible 
for  a  woman  to  carry  her  child  to  full  term  and  be  unconscious  of  the  fact  of 
pregnancy,  t 

*  For  illustrative  cases  of  feigned  pregnancy,  see  author's  article,  "Pregnancy,  Labor, 
and  the  Puerperal  State,"  "Medical  Jurisprudence,  Forensic  Medicine,"  Witthaus  and 
Becker,  vol.  11,  p.  336. 

t  Turner,  "London  Obstet.  Trans.,"  vol.  iv,  p.  113;  also  "London  Lancet,"  1861,  i,  pp. 
609-643.  For  illustrative  cases  of  unconscious  pregnancy,  see  author's  article  on  the  sub- 
ject in  Witthaus  and  Becker,  "Forensic  Medicine,"  vol.  11,  pp.  362-364. 


140  PHYSIOLOGICAL   PREGNANCY. 


VII.  MULTIPLE  PREGNANCY;    SUPERFETATION. 

Definition. — If  more  than  one  ovum  becomes  impregnated  at  the  same  or 
different  dates,  the  result  is  multiple  pregnancy;  as  twins,  triplets,  quadruplets, 
quintuplets,  sextuplets.  Fecundation  of  an  ovum  with  a  double  yolk  may 
occur.     Several  cases  of  six  children  at  a  birth  have  been  reported. 

Frequency. — Twins  occur  once  in  ninety  cases;  triplets  once  in  eight  thou- 
sand; quadruplets  once  in  four  hundred  thousand.  Multiple  pregnancies  are 
more  frequent  in  certain  countries  than  others;  for  example,  Bavaria,  Ireland, 
and  Russia.  In  2200  labors  I  found  twins  in  31  cases,  or  once  in  70  cases,  or 
1.40  per  cent. 

Etiology. — The  most  important  factor  in  the  causation  of  multiple  pregnancy 
is  heredity,  and  it  shows  itself  on  the  maternal  side  especially.  In  women  who 
have  once  given  birth  to  twins,  an  increasing  tendency  seems  to  be  present  for 
multiple  pregnancy  in  subsequent  gestations.  Multiple  pregnancy  may  arise 
(i)  from  one  or  more  ova  in  a  single  uterus;  (2)  from  two  or  more  ova  im- 
pregnated in  a  double  uterus;  (3)  from  one  ovum  or  more  in  the  uterus,  and 
one  extrauterine.  In  this  connection  two  analogous  conditions,  termed  super- 
fecundation  and  superfetation  respectively,  must  be  considered. 

Superimpregnation;  Superfecundation;  Superfetation.— The  term 
superimpregnation  indicates  the  impregnation  of  two  or  more  ova  at  the  same 
coitus;  simultaneous  fecundation.  By  the  term  superfecundation  is  meant  the 
impregnation  of  one  oviile  or  more  after  one  has  been  already  impregnated;  or 
the  fertilization  of  one  ovum  or  more  of  the  same  ovulation,  at  a  second  coitus, 
after  one  has  been  already  fecundated — successive  instead  of  simultaneous 
fecundation.  The  result  of  superfecundation  is  simply  multiple  pregnancy,  but 
the  children  may  or  may  not  differ,  according  as  they  possess  the  same  father 
or  different  fathers.  By  the  term  superfetation  is  meant  impregnation  when  an 
embryo  already  occupies  the  uterus,  or  the  fertilization  of  a  second  ovum  after 
the  development  of  the  first  ovum  has  been  going  on  in  the  uterus  for  a  month  or 
more.  Two  results  may  follow:  (i)  Two  children  are  born  at  the  same  time,  but 
different  in  development;  or  (2)  two  children  are  born  at  different  times, 
equally  developed. 

If  all  of  the  above  conditions  are  possible,  we  may  have  as  the  result  of  super- 
fecundation: (i)  The  birth  of  twins  or  triplets,  with  certain  physical  pecu- 
liarities, proving  that  they  have  had  different  fathers.  And  as  the  result  of 
superfetation:  (2)  The  birth  of  children  at  the  same  time,  differing  in  the  degree 
of  their  development;  or,  (3)  after  the  birth  of  a  mature  child,  a  second  one 
equally  developed  may  be  born,  after  the  lapse  of  several  weeks  or  months. 
That  superfecundation  may  occur  in  both  women  and  the  lower  animals  is  now 
a  matter  of  certainty.  A  mare  is  covered  by  a  stallion,  and  after  an  interval 
of  several  days,  is  covered  by  an  ass;  the  result  is  twins, — one  a  horse,  the  other 
a  mule  (Mende).  A  setter  bitch  during  the  same  ovulation  (heat)  is  covered 
successively  by  a  pointer  and  a  mastiff ;  her  puppies  plainly  indicate  the  different 
fathers.  Medical  literature  supplies  abundant  cases  to  illustrate  superfecunda- 
tion in  woman. 

For  superfetation  to  be  possible,  the  occurrence  of  ovulation  is  required 
several  weeks  or  months  after  the  fertilization  of  the  first  ovum.  The  physio- 
logical law  in  woman  is  for  ovulation  to  cease  as  soon  as  impregnation  takes 
place.  Nature  seemingly  intended  woman  to  be  uniparous,  although  we  see 
the  exceptions  in  multiple  pregnancy.     The  believers  in  superfetation  lay  stress 


MULTIPLE   PREGNANCY ;  SUPERFETATION. 


141 


Mcmbrana 
granulosa 


Fig.  182. — Graafian  Follicle  with 
Three  Ova. — (Von  Franque.*) 


upon  the  fact  that  because  women  apparently  menstruate  for  one  or  more  periods 
during  pregnancy,  therefore  ovulation  occurs  at  the  same  time.  Playfair  cites 
the  presence  of  menstruation,  as  a  proof  of  ovulation.  As  has  already  been 
pointed  out,  the  presence -of  menstruation  is  no  proof  that  ovulation  is  also 
present.     (See  Duration  of  Pregnancy.) 

Conclusions.— (i)  Superfetation  has,  in  many  instances,  been  assumed  to 
exist  without  sufficient  evidence.  (2)  There 
are  on  record  cases  that  we  are  unable  to  ex- 
plain on  any  other  ground  than  that  of  super- 
fetation.  (3)  Whether  in  all  cases  of  apparent 
superfetation  the  uterus  was  normal,  is  not 
definitely  known.  The  result  of  all  the  ob- 
servations made  upon  this  subject  is,  that  the 
majority  of  the  alleged  cases  of  superfetation 
may  be  explained  (i)  upon  the  theory  of  twin 
pregnancies,  in  which  one  fetus  has  grown  at 
the  expense  of  the  other  and  is  first  expelled, 
the  other  remaining  until  it  has  acquired  the 
proper  maturity;  (2)  by  the  existence  of  a 
double  uterus  (Fig.  457).  Nevertheless  there 
are  a  few  other  cases  which  do  not  admit  of 
either  of  these  explanations,  and  which  can- 
not be  accounted  for  except  on  the  theory  of 
two  successive  conceptions  (Reese). 

Explanation  of  Multiple  Pregnancy.: — 
There  are  various  causes  for  the  occurrence  of 
multiple  pregnancies.     The  most  frequent  is 

probably  the  coincident,  or  almost  coincident,  rupture  of  simultaneously  matured 
Graafian  follicles,  whose  ova  are  iinpregnated  at  the  same,  or  very  nearly  the 
same,  time.  As  a  general  rule,  twins  develop  from  two  distinct  ova,  which  are 
derived  from  the  same  or  different  Graafian  folHcles.  They  may  be  situated  in 
different  ovaries,  as  proved  by  the  presence  and  position  of  the  corpora  lutea. 

So  twins  may  be  derived  (a)  from  one  ovum  from  each 
ovary;  (6)  from  two  ova  from  one  ovary;  (c)  from  a 
double  ovum,  both  nuclei  being  fertilized  (Fig.  183); 
{d)  from  a  division  which  takes  place  in  the  blasto- 
derm, giving  rise  usually  to  monsters,  but  sometimes 
to  twins  (Fig.  93).  The  presence  of  a  double  nucleus 
may  be  assumed  when  twins  are  derived  from  a  single 
ovum,  but,  as  emphasized  by  Ahlfeld  in  his  researches 
on  the  production  of  double  monsters,  the  possibility 
must  be  entertained  that  the  twins  may  have  resulted 
from  complete  fission  of  a  single  germ.  The  twins  are 
then  termed  "homologous,"  and  their  mental  and 
physical  similarity  is  striking.  Twins  originating 
from  a  single  ovum  are  always  of  the  same  sex,  while 
those  from  two  ova  may  be  of  the  same  sex  or  of  different  sexes.  Triplets  may 
be  derived  from  one,  two,  or  three  ova.  A  common  method  is  for  one  child  to 
originate  from  one  ovum,  while  the  other  two  are  derived  from  another  single 
ovum.     The  arrangement  of  the  placentae  and  membranes  will  depend  upon  the 

*  "Zeitschrift  f.  Gebvirts.  u.  Gynakol.,"  Bd.  xxxix. 
t  "  Zeitschrift  f,  Geburts.  u.  Gynakol.,"  Bd.  xxxix. 


Fig.  183. — Two  Primor- 
dial Follicles  in  One 
OF  Which  is  an  Ovum 
with  Two  Germinal 
Vesicles. — {Von  Fran- 
que.'t) 


142 


PHYSIOLOGICAL  PREGNANCY. 


DECIDUA 
SEROTIW, 


ECIDUA 

EROTINA 


method  of  their  origin.     Quadruplets  may  consist  of  double  twins,  or  of  triplets 
together  with  a  single  child. 

Membranes. — As  to  the  arrangement  of  the  fetal  membranes,  the  decidua 

vera  is  invariably  single ;  the  decidua  refiexa 
is  double  when  the  ova  are  attached  to  parts 
of  the  uterine  wall  widely  separated.  The 
chorion,  since  it  takes  its  origin  primarily 
from  the  zona  pellucida,  is  single  when  the 
twins  are  derived  from  two  nuclei  within 
a  single  ovum,  but  double  when  they 
originate  from  separate  ova.  Originally 
the  amnion  is  always  double,  for  it  is 
elaborated  as  an  outgrowth  extending  from 
the  embryo  itself.  When  twins  are  in  one 
common  membrane,  there  has  been,  as 
noted  before,  an  absorption  of  the  septum 
which,  for  a  time,  served  as  a  barrier  (Figs. 
184,  185,  and  186). 

Placenta. — Primarily  the  placenta  is 
double,  for  each  fetus  produces  its  own 
allantois  and  the  placental  region  result- 
ing therefrom.  In  the  case  of  twins  com- 
ing from  different  ova,  the  placenta  may 
remain  separate,  but  even  in  this  case 
fusion  of  the  placental  areas  finally  occurs.  There  is  almost  without  excep- 
tion an  anastomosis  of  the  vessels  of  the  placentae  of  single-egged  twins, 
consequently  the  placentae  are  fused  to  a  certain  extent,  and  there  results 
a    common    area    of   nutrition  for  both  fetuses;    while  there    are   two    other 


Fig.  184. — Twin  Pregnancy  Result- 
ing FROM  Two  Ova  from  the  Same 
OR  Different  Graafian  Follicles 

AND     FROM    THE     SaME     OR    OPPOSITE 

Ovaries.  First  arrangement  of  fetal 
structures.  A.M.,  Amnion.  The 
heavy  black  portion  indicates  the 
chorion. — (Dakin.) 


DECIDUA  SEROTINA 


-  DECIDUA 
SEROTI 


DECIDUA 
SEROTINA 


DECIDUA 
VERA 


DECIDUA 

VERA 

'DECIDUA 
REFLEXA   ^ 


Fig.  185. — Twin  Pregnancy  from  One 
Ovum  with  Two  Germinal  Spots. 
Second  arrangement  of  fetal  structures. 
A.M.,  Amnion.  The  heavy  black  por- 
tion indicates  the  chorion. — (Dakin.) 


DECIDUA 
VERA 


DECIDUA 
VERA 
DECIDUA 
REFLEXA 


Fig.  186. — Twin  Pregnancy  from  One 
Ovum  with  One  Germinal  Spot.  Third 
arrangement  of  fetal  structures.  A.M., 
Amnion.  The  heavy  black  portion  in- 
dicates the  chorion. — (Dakin.) 


areas,  one  for  the  special  use  of  each  fetus  (Hyrtl).  Hence,  if  there 
are  two  distinct  ova,  there  may  be  expected  two  sets  of  membranes, 
while  in  the  case  of  one  ovum  with  two  nuclei,  a  double  amnion  but  a  single 


MULTIPLE   PREGNANCY;  SUPERFETATION.  143 

chorion,  and  a  single  placenta  will  probably  develop.  Sometimes  only- 
one  amnion  is  found,  in  which  case  the  partition  between  the  two  has 
probably  been  dissolved.  Veit  found  in  429  cases,  that  383  were  from 
two  distinct  ova,  46  from  a  single  ovum,  and  two  had  a  single  amnion. 
Ahlfeld  found  a  single  amnion  in  456  cases,  or  half  as  frequently  as  Veit. 
In  a  twin  pregnancy  with  one  placenta  it  is  very  necessary  to  tie  the  cord 
of  the  infant  first  born,  for  the  second  may  bleed  to  death  from  the  cord 
of  the  first. 

Abnormal  Conditions. — The  circulation  of  one  child  may  be  more  fully 
developed  than  that  of  the  other,  so  that  the  second  becomes  a  monster.  There 
may  be  a  marked  amount  of  fluid  in  one  sac  and  very  little  in  the  other  (Ahl- 
feld). The  anastomoses  of  the  vessels  of  the  placenta  may  exert  a  very  strong 
influence  on  the  development  of  the  twins.  Circulation  from  the  weaker  may 
be  directed  almost  entirely  to  the  stronger,  and  there  will  result,  in  the  case  of 
the  first,  fetal  atrophy,  or  acardia.  In  case  of  the  death  of  one  fetus,  the  living 
child  will,  in  its  growth,  compress  the  dead  child  more  and  more  till  it  becomes 
a  flattened  mass  pressed  against  one  side  of  the  uterine  wall,  and  known  as  the 
"fostus  papyraceus"^  (Fig-  445)-  There  may  be  a  striking  difference  between  the 
infants  at  birth,  the  one  being  large  and  vigorous,  the  other  small  and  puny. 
Now  and  then  it  happens  that  the  larger  child  is  born  at  term,  and  the 
immature  fetus  is  retained  till  it  has  become  more  like  its  fellow,  when 
it  is  likewise  expelled.  Cases  of  double  uteri  have  been  recorded  in  which 
two  children  of  the  same  mother  have  been  born  a  month  or  more  apart 
(Barker,  Generali). 

Symptoms  and  Diagnosis. — Often  there  are  no  subjective  symptoms  to  point 
to  this  interesting  condition.  Usually  all  the  symptoms  of  pressure  and  con- 
gestion, and  sometimes  the  reflex  and  sympathetic  disturbances,  are  exag- 
gerated. As  a  rule,  the  duration  of  pregnancy  is  shortened  by  about  two  weeks, 
by  reason  of  the  overdistention.  The  uncertain  signs  are:  (i)  exaggerated 
pressure,  and  congestive  symptoms;  (2)  excessive  size  and  irregularity  of  the 
uterine  tumor,  with  (3)  increased  tension  of  the  uterine  walls,  and  (4)  diminished 
fetal  mobility.  The  certain  signs  are:  (i)the  palpation  of  similar  parts  of  the 
fetus,  as  two  heads,  two  breeches,  a  number  of  fetal  extremities,  or  after  dilatation 
of  the  OS,  two  bags  of  membranes.  (2)  The  detection  of  two  or  three  fetal  heart 
sounds  at  different  points  of  the  abdomen,  of  the  same  degree  or  of  different 
degrees  of  intensity,  and  separated  by  areas  over  which  the  sounds  are  absent  or 
indistinctly  heard.  Errors  in  diagnosis  are  the  result  of  depending  too  much  on 
this  sign;  in  the  case  of  a  uterus  containing  a  large  fetus,  with  little  liquor  amnii, 
and  covered  by  thin  maternal  abdominal  walls,  the  fetal  heart  may  be  heard 
more  or  less  distinctly  over  the  entire  uterine  surface,  and  unless  two  observers 
auscultate  and  count  at  the  same  time,  differences  in  heart  rate  and  intensity 
may  appear  to  be  present.  I  made  this  mistake  early  in  my  private  prac- 
tice; the  child,  a  male,  weighed  9 J  pounds.  (3)  The  detection,  by  bimanual 
palpation,  of  two  fetal  poles  in  the  uterus.  Thus,  with  two  fingers  in  the  vagina 
upon  the  presenting  fetus,  upon  pushing  this  fetal  pole  upward,  the  hand  upon 
the  fundus  will  perceive  an  absence  of  motion  in  one  fetal  pole,  and  the  conveyed 
impulse  of  the  vaginal  palpation  in  the  other.  This,  in  my  experience,  is  the 
most  reliable  sign,  as  I  have  frequently  demonstrated  to  students  in  the 
clinic. 

Prognosis. — The  dangers  for  the  mother  are:  (i)  greater  liability  to  toxemia  of 
pregnancy  and  eclampsia,  on  account  of  the  increased  metabolism  of  the  two  or 

*  See  Amorphus  anideus,  Fig.  391. 


144  PHYSIOLOGICAL  PREGNANCY. 

more  fetuses,  and  the  greater  pressure  on  the  kidneys  and  ureters.  My  study 
of  31  cases  of  twins  shows  albuminuria  almost  constantly  present.  (2)  Uterine 
inertia,  prolonged  labor,  and  post-partum  hemorrhage  are  liable  to  occur  as  a 
result  of  the  extreme  uterine  distention.  (3)  Abnormal  presentations  may  be 
present  as  the  result  of  irregularity  in  the  shape  of  the  uterine  cavity.  (4)  Pre- 
mature expulsion  of  the  fetuses  occurs  in  about  25  per  cent.,  with  greater  ten- 
dency to  placental  retention.  The  fetal  prognosis  is  affected  by:  (i)  Deficient 
development  of  one  or  both  twins;  the  stronger  and  better-developed  twin 
attracts  more  nourishment,  and  crowds  and  perhaps  kills  its  fellow  (fcetus  papy- 
raceus) ;  or  lack  of  fetal  movement  results  in  poor  muscular  development  of 
the  extremities  and  bodies  of  both  twins.  (2)  In  unioval  twins  anastomosis 
between  fetal  and  placental  vessels  is  apt  to  produce  monsters.  (3)  Hydramnios 
is  frequent.  (4)  Complications  of  malpresentation  and  position  may  occur  at 
the  time  of  birth.  Thus,  (a)  compound  presentations,  as  double  head,  double 
breech,  and  head  with  breech,  or  breech  with  extremities;  (6)  malpresentations, 
as  shoulder  presentation  of  second  child  (10  per  cent.);  (c)  coiling  and  twisting 
of  the  cords  after  the  onset  of  labor;  {d)  locking  and  welding,  an  engagement 
and  interlocking  of  both  heads,  locking  of  a  head  or  breech  with  a  shoulder 
presentation,  interlocking  of  chins,  interlocking  of  occiputs.* 
Phenomena  of  Labor.     See  Part  V. 


VIII.    THE    DURATION    OF   PREGNANCY.     PROTRACTED 

GESTATION. 

Definition. — By  the  actual  duration  of  pregnancy  we  understand  the  time 
that  elapses  between  impregnation  and  labor.  The  duration  we  are  unable  to 
obtain  in  any  case  with  exactness,  since  the  date  of  conception  is  always  un- 
known. The  uncertainty  is  due  to  two  facts:  First,  there  may  exist  an  interval 
of  from  one  to  fourteen  days  between  the  time  of  insemination  and  fertilization 
of  the  ovum;  and,  second,  it  is  impossible  to  know  in  a  given  case  whether  the 
ovum  which  is  fertilized  is  the  product  (i)  of  the  last  menstrual  epoch,  (2)  of 
the  intermenstrual  period,  (3)  of,  or  the  date  corresponding  with,  the  first  sup- 
pressed period.  The  real  duration  of'  pregnancy,  therefore,  in  the  human 
female  is  an  unknown  quantity. 

The  Average  Duration. — We  learn  from  experience  that  the  average  apparent 
duration  of  pregnancy  is  ten  lunar  or  nine  calendar  months,  or  forty  weeks, 
or  two  hundred  and  eighty  days  from  the  beginning  of  the  last  menstrual  period, 
or  two  hundred  and  seventy-two  days  from  the  date  of  conception.  Schlichtingf 
investigated  456  cases,  and  made  the  average  to  be  269.5  days;  and  yet  the  time 
varied  from  two  hundred  and  forty  to  three  hundred  and  thirty-four  days. 
Winckel,J  in  his  5010  cases  examined,  found  70  in  which  the  duration  of  gestation 
was  more  than  three  hundred  days,  and  in  6.8  per  cent,  of  those  cases  in  which 
the  exact  date  of  impregnation  was  considered  known,  the  duration  was  more 
than  three  hundred  days;    in  one  case  the  duration  was  three   hundred   and 

*  In  31  twin  labors  in  hospital  practice  I  fotind  the  maternal  mortality  o  per  cent. 
Both  children  lived  in  24  cases,  or  77.41  per  cent.,  and  one  lived  and  one  was  still-bom  in 
6,  or  19.35  psr  cent.  Labor  was  natural  m  20  cases,  or  64.51  per  cent.;  the  forceps  was  re- 
quired in  4  instances  (once  in  eight  cases) ;  version  in  4  and  breech  extraction  in  i. 

t  "Arch.  f.  Gynak.,"  Bd.  xvi,  210. 

X  "Text-book  of  Midwifery,"  1890,  p.  94. 


DURATION   OF  PREGNANCY ;  PROTRACTED   GESTATION.     145 

fourteen,  and  in  another  three  hundred  and  eighteen  days.  Lowenhardt,* 
from  518  cases  in  which  the  women  could  give  the  date  of  the  fruitful  coitus, 
found  that  the  average  duration  of  pregnancy  from  the  date  of  conception  was 
272.2  days.  Leuckardt,  from  an  analysis  of  67  cases  found  upon  the  marriage 
and  birth  register  of  a  church,  in  which  labor  occurred  within  ten  months  after 
the  marriage  night,  computed  the  average  duration  of  pregnancy  to  be  272.5 
days.  Hasler,t  from  a  large  number  of  cases  in  which  the  date  of  the  impreg- 
nating coitus  was  known,  estimated  the  average  duration  of  pregnancy  to  be 
272.24  days  from  the  dateof  conception,  and  280.5  days  from  the  beginning  of 
the  last  menstrual  epoch.  Issmer,|  in  an  exhaustive  paper  upon  the  duration 
of  pregnancy,  based  on  a  careful  analysis  of  464  cases,  has  given  the  following 
interesting  conclusions:  (i)  Conceptions  occurring  in  the  first  half  of  the  inter- 
menstrual period  are  to  those  in  the  second  half  as  72  to  27.  (2)  Pregnancies 
dated  from  the  first  half  of  the  intermenstrual  period  are  shorter  in  duration 
than  those  dated  from  the  second  half.  (3)  When  impregnation  occurs  in  the 
first  half,  the  ovum  fertilized  is  that  which  was  discharged  at  the  last  men- 
struation (ovulation);  while  when  it  occurs  in  the  second  half,  the  ovum  im- 
pregnated is  one  that  escapes  at  or  near  the  next  menstrual  period.  (4)  The 
average  duration  of  pregnancy  is  two  hundred  and  sixty-eight  days  from  con- 
ception, or  two  hundred  and  seventy-eight  days  from  the  completion  of  the  last 
menstruation.     The  maximum  duration  is  three  hundred  and  four  days. 

Authorities  differ  somewhat  in  giving  the  average  duration  of  gestation  in  the  human 
subject.  Thus  (calculated  from  the  first  day  of  the  last  menstruation) :  Schlichting  §  (440 
cases)  gives  273.1  days;  Matthew  Duncan  ||  gives  278  days;  Lowenhardt-Ahlfeld  ^  (166 
cases)  gives  281.6  days;  Hasler  (large  number) ,  280.5  days.  And,  calculating  from  concep- 
tion, Schlichting,**  456  cases,  gives  269.5  days;  Lowenhardt, ft  S18  cases,  gives  272.5  days; 
Leuckardt, tt  67  cases,  gives  272.5  days;  Hasler, §§  large  number,  gives  272.24  days. 

Protracted  Gestation. — A  case  is  reported  by  Thomson  ||||  in  which  gestation  lasted  317 
days  from  the  last  menstrual  period,  or  301  from  the  last  sexual  intercourse.  Kriiche^^  re- 
ported a  case  in  which  he  believed  the  duration  of  pregnancy  was  330  days.  The  latest  period 
to  which  pregnancy  may  be  protracted  is  stated  by  various  authors  as  follows:  Depaul,  300 
days  (high  limit) ;  Robert  Barnes,  300  days  (improbable) ;  Issmer,***  304  days;  Winckel,ttt 
320  days;  Schr6der,ttJ  320  days;  Schlichting, §§ §  334  days;   Runge,||||||  320  days. 

Reese  TflfTf  states  that  it  is  possible  for  pregnancy  to  be  prolonged  beyond  the  usual 
period  accepted  as  the  average,  but  he  gives  no  limit. 

As  to  the  legitimacy  of  offspring  according  to  the  duration  of  pregnancy,  different  coun- 
tries possess  different  laws.  In  Austria****  the  law  recognizes  the  legitimacy  of  the  child 
bom  within  240  to  307  days  after  the  death  of  the  father.  In  France tftf  "the  legitimacy 
of  the  infant  bom  300  days  after  the  dis.solution  of  the  marriage  is  liable  to  be  contested." 
In  England  and  America  "the  light  of  the  courts  in  this  matter  is  reflected  light.  Physicians 
must  determine  the  matter;  and  if  the  space  between  the  minimum  and  maximum  periods 
hitherto  allowed  is  shown  to  be  too  long  or  too  short,  the  courts  will  readily  follow  the  truth 
as  it  is  made  manifest."  In  Wharton  "On  Evidence"  (sec.  i,  300)  we  find  no  absolute 
limit  laid  down.  Each  case  is  determined  upon  its  merits.  A  liberal  view  is  taken,  and  the 
legitimacy  of  births  at  the  completion  of  313  and  317  days  respectively  has  been  judicially 
decided.  This  limit  of  317  days  is,  according  to  most  medical  authorities  on  the  subject,  an 
extreme  one. 

*  "Arch.  f.  Gynak.,"  in,  1782. 

t  "Ueber  die  Dauer  der  Schwangerschaft,"    Zvirich,  1876. 

t  "Arch.  f.  Gynak.,"  xxxv,  1889,  p.  310.  §  "Arch.  f.  Gynak.,"  Bd.  xvi,  210. 

II  Ibid.,  Bd.  Ill,  456.  t  "Monat.  f.  Geburtsh.,"  xxxiv,  180,  S.  266 

**  Loc.  cit.  tt  Loc.  cit.  Jt  Loc.  cit.  §§  Loc.  cit. 

III!  "Trans.  London  Obstet.  Soc,"  vol.  xxvii. 
^1f  "Deutsche  med.  Zeitung,"  von  Grosser,  1883,  370. 

***  "Arch.  f.  Gynak.,"  Bd.  xvi,  210.  ttt  "Text-book  of  Midwifery,"  1890,  p.  94 

ttt  "Lehrb.  der  Geburtsh.,"  9te.  Aufl.,  Bonn,  18S6',  p.  109. 

§§§  "Arch.  f.  Gynak.,"  Bd.  xvi,  210.  ||||||  "Lehrb.  d.  Geburtsh iilfe,"  Berlin,  1891 

lift  "Text-book  of  Med.  Jur.  and  Tox.,"  Phila.,  1889. 

****  "Das  k.  k.  Oesterreichische  burgerliche  Gesetzbuch,"  "Amer.  Sys.  Obstet.,'    vol.  i. 
tttt  L'article  315  du  code  civil. 
10 


146 


PHYSIOLOGICAL   PREGNANCY. 


IX.  CALCULATING  THE  DATE  OF  CONFINEMENT. 

1.  When  the  Date  of  a  Single  Cohabitation  is  Known. — Add  280  days,  or 
(Naegele's  rule)  count  back  three  months  from  the  date  of  cohabitation,  and  add 
seven  days  for  impregnation.  In  leap  years,  after  February  6th,  the  number  of 
da^'-s  to  be  added  varies  according  to  the  month;  e.  g.,  in  February,  four  days; 
in  December  and  January,  five  days;  in  April  and  September,  six  days, 

2.  When  the  Date  of  the  Last  Menstruation  is  Depended  Upon. — (i)  Count 
back  three  months  from  the  appearance  of  the  last  menstruation,  and  add  ten 
days,  three  for  menstruation  and  seven  for  impregnation.  The  first  day  of  the 
last  menstruation  is  a  date  far  more  readily  obtained  than  the  date  of  cessation, 
and  is  the  best  time  to  count  from.  (2)  Duncan's  rule:  Add  to  the  last  day 
of  the  last  menstruation,  nine  months,  which  should  be  counted  as  275  days, 
unless  February  be  one  of  the  months,  in  which  case  the  period  will  be  273  days. 
To  the  date  thus  obtained,  add  three  days  in  the  former  case,  and  five  in  the 
latter,  which  will  make  278  days.  This  two  hundred  and  seventy-eighth  day 
will  be  the  middle  of  the  fortnight  in  which  labor  will  be  apt  to  take  place.  (3) 
Lowenhardt's  method:  Reckoning  is  made  of  the  number  of  days  between  the 
last  menstrual  epoch  and  the  one  preceding  that.  This  result,  multiplied  by 
10,  will  represent  ten  menstrual  periods,  and  will  be  very  accurate. 

3.  When  the  Date  of  the  Last  Menstruation  is  Unknown. — If  a  woman  becomes 
pregnant  when  she  is  not  menstruating, — in  lactation,  for  example, — or  when 
from  any  other  reason  the  date  of  the  last  menstruation  cannot  be  ascertained, 
some  method  must  be  employed  which  does  not  take  this  into  account ;  such  as 
(i)  counting  from  the  date  of  quickening;  (2)  height  of  the  fundus;  (3)  men- 
suration of  the  fetus  in  utero;  (4)  time  of  lightening;  (5)  changes  in  the  cervix, 
(i)  From  date  of  quickening:  Count  from  the  first  appearance  of  the  "quick- 
ening," which,  on  the  average,  appears  at  the  seventeenth  week.  To  this  date 
is  added  four  and  one-half  months,  in  order  to  estimate  roughly  the' date  of 
confinement.  (2)  From  the  height  of  the  fundus  an  approximate  idea  may  be 
obtained;  fourth  month,  the  fundus  occupies  the  hypogastrium ;  fifth  month, 
midway  between  symphysis  and  umbilicus;  sixth  month,  on  a  level  with  the 
umbilicus  or  just  above;  seventh  month,  midway  between  the  umbilicus  and 
xiphoid  cartilage;  eighth  month,  at  xiphoid  cartilage;  ninth  month,  descends 
almost  to  depth  at  which  it  was  in  seventh  month,  the  presenting  part  having 
entered  the  pelvic  brim  in  primigravidas.  On  account  of  the  variations  in  the 
position  of  the  umbilicus,  Spiegelberg  estimated  the  height  of  the  fundus  above 
the  symphysis  in  the  different  weeks  of  pregnancy.     His  results  are  appended: 


From  22d  to  26th  week  ftuidus  of  uterus  8.56  inches  (20.0  cm.)  above  symphysis. 
At  the  28th 

"  32d-33d 

"  34th 

"  35th-36th 

"  37th-38th 

"  39th-4oth 


10.43 

(25.0  cm.)       "              " 

"       11.02        ' 

(27.5  cm.) 

II. 81 

(29.0  cm.)       "              " 

"       12.00       ' 

(30.0  cm.) 

12.50       ' 

(31. S  cm.) 

12.99 

(33.0  cm.) 

"       13-39        ' 

(34.5  cm.) 

(3)  By  measurement  of  the  fetal  ellipse:  On  account  of  the  variations  in  individual 
pelves,  and  the  importance  in  contracted  pelves  of  the  size  of  the  fetus,  Ahlfeld 
has  paid  much  attention  to  the  measurement  of  the  child  in  utero.  The  fetal 
ellipse  in  the  last  months  of  pregnancy  is  nearly  half  the  length  of  the  fetus; 
i.  e.,  the  length  of  the  long  axis  of  the  fetus,  as  it  lies  flexed  in  the  uterus,  is  about 


CALCULATING   THE  DATE  OF  CONFINEMENT. 


147 


half  the  length  of  the  extended  fetus  (Fig.  187).  These  measurements  are  taken  by- 
means  of  calipers,  one  end  of  which  is  rested  against  the  presenting  part  in  the 
vagina,  and  the  other  against  that  part  of  the  fetus  in  the  fundus  of  the  uterus. 
Thus,  whenever  a  measurement  is  taken  of  the  fetal  ellipse,  it  will  represent  half 
the  length  of  the  fetus  at  that  particular  date.  The  table  below  gives  the  corre- 
sponding length  of  the  fetal 
ellipse,  of  the  extended 
fetus,  and  its  weight  at  va- 
rious weeks  of  its  growth. 
This  method  is  used  when 
the  fetus  presents  longitu- 
dinally. When  the  pres- 
entation is  transverse,  the 
measurement  is  purely  ab- 
dominal. (4)  The  phe- 
nomenon of  lightening  at 
the  beginning  of  the  pre- 
paratory stage  to  labor,  al- 
though its  value  in  fore- 
telling the  day  of  delivery- 
is  not  great .  ( 5 )  Changes  in 
the  portio  vaginalis  and  cer- 
vical canal  \x\.\aiq,\c^\Xqx'^zx\,  Fig.  187. — Calculating  the  Date  of  the  Expected 
of  pregnancy,  especially  in  Confinement  by  Measuring  the  Fetal  Ovoid  with 

__:^-~-ro^ri'/^':o         ^\^^^^AA       Vvo  O^^  PoiNT  OF  THE  PELVIMETER  ON  THE  FeTAL  HeAD  IN 

primigraviaas,     snouia     oe         ^^^  Vagina,  and  the  Other  on  the  Breech  through 
taken  into  consideration.  the  Anterior  Abdominal  Wall. 


Period  of  Preg- 
nancy. 

Axis  of  Fetal  Ellipse. 

Total  Length  of  F 

STUS. 

Weight  of  Fetus. 

At  the  20th  week 

3.82  to  5.79  in.  (9.7  to 
14.7  cm.) 

7.08  to  10.62  in. 
to  27  cm.) 

(18 

9.8  oz.  (280  grams) 

"       24th     " 

5.90  to  7.36  in.  (15.0  to 
18.7  cm.) 

11.02  to  13.48  in. 
to  34  cm.) 

(28 

1.39s  lbs.  (634  grams) 

28th     " 

7.08  to  8.97  in.  (18.0  to 
22.8  cm.) 

13.88  to  14.96  in. 
to  38  cm.) 

(35 

2.64  lbs.  (1200  grams) 

32d       " 

9.45  to  10.82  in. (24.0  to 

14.96  to  16.93  i^' 

(38 

3.52  to  4.18   lbs.    (1600 

27.5  cm.) 

to  43  cm.) 

to  1900  grams) 

36th     " 

10.63  to  II. 81  in.  (27.0 

16.52  to  18.90  in. 

(42 

3.74  to  5.72  lbs.   (1700 

to  30.9  cm.) 

to  48  cm.) 

to  2600  grams) 

"        40th     " 

II. 81  to  14.56  in.  (30.0 

18.90  to  20.47  i^' 

(48 

6.60  to  7.92  lbs.   (3000 

to  37.0  cm.) 

to  52  cm.) 

to  3600  grams) 

The  exact  day  of  delivery  probably  depends  on  small  details,  either  mental 
or  physical.  Impregnation  has  been  observed  to  occur  at  any  time  in  the  men- 
strual month,  although  considered  to  take  place  more  frequently  in  the  few 
days  just  preceding,  and  those  immediately  following,  menstruation.  Some 
women  always  seem  to  exceed  the  normal  limits  of  pregnancy,  and  in  such  cases 
the  child  is  usually  a  large-sized  male.  In  other  cases  the  duration  of  pregnancy 
is  shorter  than  usual;  it  is  said  to  be  so,  early  and  late  in  the  reproductive  age, 
and  in  single  women,  while  it  is  long  in  the  middle  part  of  the  child-bearing 
period.  It  is  quite  likely  that  the  gestation  period  corresponds  with  the  length 
of  the  individual's  menstrual  cycle.  If  fecundation  takes  place  a  few  days 
after  the  close  of  a  menstrual  period,  the  next  menstrual  period  is  almost 
invariably  suppressed.     If,  however,  it  occurs  a  few  days  before  a  menstrual 


148  PHYSIOLOGICAL  PREGNANCY. 

epoch,  then  there  may  be  an  irregular  or  atypical  menstruation  succeeding. 
In  the  case  of  a  woman  with  an  irregular  menstrual  history  the  difficulties  of 
calculation  increase. 


X.  THE  EXAMINATION  OF  PREGNANCY. 

No  better  time  than  that  of  the  examination  of  pregnancy  can  be  selected 
for  inculcating  in  the  student  the  principles  of  obstetrical  cleanliness,  mechanical 
and  chemical.  The  principles  of  personal  cleanliness  and  disinfection,  if  not 
learned  now,  are  less  likely  to  be  acquired  afterwards.  While  it  cannot  be  stated 
that  the  same  danger  attends  vaginal  examinations  in  pregnancy  as  in  labor, 
still,  in  the  latter  part  of  pregnancy,  the  examining  finger  often  enters  the  cer- 
vical canal,  and  in  the  one  or  more  weeks  of  the  preparatory  stage  of  labor  the 
conditions  are  often  quite  analogous  to  active  labor.  Moreover,  the  possibility 
of  a  low  placental  attachment,  or  even  of  actual  labor,  must  always  be  granted. 
For  these  reasons  obstetric  asepsis  demands  that  the  same  rigid  cleansing  of  the 
hands  and  forearms,  and  precautions  in  separation  of  the  sides  of  vulva,  be  ap- 
plied to  the  examination  of  pregnancy,  as  to  that  of  labor  and  the  puerperium. 

Obstetric  Asepsis. — In  Vienna,  in  1847,  the  foundation  of  aseptic  midwifery 
was  laid  by  Semmelweis,  and  perfected  by  others  along  the  lines  laid  down 
by  Pasteur  and  Lister.  Semmelweis,  in  1847,  discovered  the  septic  nature  of 
puerperal  fever,  and  by  means  of  chlorine  solutions  instituted  an  antiseptic  pro- 
phylaxis against  the  scourge.  In  brief,  puerperal  fever  was,  according  to  Sem- 
melweis, no  new  specific  disease,  but  a  variety  of  pyemia. 

At  the  beginning  of  the  present  century  the  consensus  of  opinion  was  that 
the  pregnant  vagina  and  gravid  and  puerperal  uterine  cavity  were  quite  sterile 
under  normal  conditions,  and  that  autoinfection  from  these  sources  was  quite 
impossible  except  in  rare  instances.  In  other  words,  septicemia  was  in  the 
vast  majority  of  cases  a  disease  introduced  from  without.  The  evidence  upon 
which  this  view  rested,  including  the  result  of  the  labors  of  Bumm,  Kronig, 
and  others,  was  thought  to  be  irrefutable.  Of  course,  theories  were  not  wanting 
to  explain  this  supposed  sterility  of  the  birth-tract,  and  the  chief  of  them  had 
reference  to  the  bactericidal  power  oi  the  vaginal  secretion  and  lochia,*  each 
of  which  was  pronounced  to  be  not  only  a  poor  culture-medium,  but,  moreover, 
endowed  with  powers  of  self -purification,  even  after  the  introduction  of  an 
abundance  of  germ-life.  This  theory  was  in  excellent  accord  with  practice, 
for  it  inculcated  the  greatest  thoroughness  in  obstetric  asepsis  and  made 
the  practitioner  practically  responsible  for  the  occurrence  of  an  aseptic  puer- 
perium. From  this  point  of  view  I  trust  the  profession  will  never  recede,  but 
as  a  matter  of  fact  the  views  thus  held  as  a  scientific  gospel  have  within  the 
past  few  years  been  completely  undermined  by  new  discoveries.  An  increasing 
number  of  observers  have  found  that  the  healthy  vagina  of  the  pregnant  woman 
is  by  no  means  always  sterile;  and  that  streptococci  pathogenic  to  animals 
may  be  recovered  from  not  a  small  proportion  of  cases.  Two  of  the  most 
recent  authorities,  von  Rosthorn  t  and  Lenhartz.J  accept  the  view  that  the 
vagina  is  not  sterile,  and  possesses  no  inherent  bactericidal  power.     At  the 

*  As  will  be  seen  later,  the  lochia  does  possess  such  powers,  although  they  are  hardly  in 
force  directly  after  delivery. 

fvon  Winckel:  "  Handbuch  d.  Geburtshulfe,"  Bd.  i,  1903. 
J  "  Die  septische  Erkrankungen,"  1903. 


THE   EXAMINATION   OF  PREGNANCY.  149 

same  time,  Franz,*  Schauenstein.t  Wormser,|  and  others  have  shown  that 
ordinary  saprophytes  and  streptococci  invade  the  uterine  cavity  immediately 
after  labor  in  a  very  large  number  of  cases.  Walthard  ^  claims  that  vaginal 
germs  at  times  readily  pass-into  the  non-pregnant  uterus,  where  they  may  set 
up  endometritis  and  toxemia.  The  locomotive  powers  of  virulent  streptococci 
in  cultures  is  of  course  well  known;  for  example,  according  to  Bumm,||  these 
germs,  after  having  inoculated  birth-traumas  in  the  vulval  region,  can  migrate 
into  and  infect  the  endometrium  in  twenty-four  hours,  while  the  rapid  decom- 
position of  retained  decidual  and  placental  structures  shows  that  saprophytes, 
whatever  their  source,  have  ready  access  to  the  puerperal  uterus.  Sepsis  of 
grave  character  occurs  not  rarely  in  women  who  have  never  been  submitted 
to  the  examination  of  pregnancy  and  in  those  who  have  been  examined  with 
sterilized  gloves. 

According  to  the  older  views,  the  external  genitals  alone  abounded  in  germ 
life,  and  much  of  the  puerperal  morbidity  could  be  attributed  to  the  accidental 
transportation  of  these  germs  into  the  vagina  by  the  examining  finger,  and  by 
manipulation  on  the  part  of  the  patient. 

I  found  that  the  secretion  in  the  vulval  canal,  in  twenty-eight  pregnant 
and  two  parturient  women  in  the  Emergency  and  Maternity  Hospitals,  showed 
pyogenic  bacteria  in  forty  per  cent,  of  the  cases :  Staphylococcus  pyogenes  albus 
in  8  cases.  Staphylococcus  pyogenes  aureus  in  3  cases,  and  Streptococcus  pyogenes 
in  one  case.  In  all  but  two  of  the  cases  the  external  genitals  were  washed  with 
soap  and  water  just  previous  to  the  taking  of  the  cultures. T[ 

Vaginal  Examinations  and  Manipulations. — We  may  accept  the  following 
statement  as  probable:  The  microbes  which  are  known  to  cause  puerperal 
morbidity  may  or  may  not  be  present  in  the  healthy  vagina.  From  the  very 
large  proportion  of  cases  in  which  they  invade  the  uterus  immediately  after 
labor  "the  chances  are  that  the  majority  of  vaginas  contain  germs.  These, 
while  comprising  even  Streptococcus  pyogenes  in  a  goodly  proportion  of  cases, 
must  not  straightway  be  regarded  as  pathogenic;  they  may  or  may  not  be 
so.  The  question  must  arise,  "If  we  believe  that  the  vagina  in  a  very  large 
proportion  of  cases  contains  germs  which  are  almost  certain  to  pass  into  the 
uterus  after  delivery,  and  which  while  not  necessarily  or  ordinarily  pathogenic 
may  still  be  the  cause  of  severe  and  even  fatal  sepsis  under  certain  circum- 
stances, should  we  return  to  the  old  custom  of  antiseptic  douching  of  the  vagina 
as  a  routine  practice?"  At  present  this  question,  it  must  be  confessed,  is  by 
no  means  easy  to  answer  offhand.  Such  antisepsis  is  still  practised  as  a  pro- 
cedure of  necessity  in  selected  cases,  as  in  suspected  gonorrhea,  before  manual 
or  operative  delivery,  etc.  (See  Part  X.)  We  have  no  means  of  differentiating 
between  sterile  and  non-sterile  vaginal  secretions,  for  Doderlein's  distinction 
between  normal  and  pathological  secretions — the  latter  having  an  alkaline 
reaction  and  excess  of  formed  elements — has  little  practical  value.  We  know 
in  advance  that  the  majority  of  cases  in  the  absence  of  vaginal  antisepsis  will  go 
through  the  puerperium  without  morbidity.  We  may  also  feel  fairly  positive 
that  a  certain  proportion  of  women  will  in  the  long  run  undergo  more  or  less 
severe  sepsis,  with    secondary  morbidity,  and   perhaps   some   fatalities.     But 

*  Franz;  "  Hegar's  Beitrage  z.  Geburtshulfe , "  1902,  vi.  f  Cited  by  Franz,  v.  supra. 

J  Ibid.  ^Walthard:  "  Zeitschr.  f.  Geburts.  u.  Gyn.,"  1902,  xlvii. 

II"  Grundriss  zum  Studium  des  Geburtshulfe,"  1902,  p.  655. 

If  See  author's  experiments  on  13  primigravidas  and  17  multigravidas  at  Emergency  and 
New  York  Maternity  Hospitals.  "  Asepsis  in  Obstetrics,"  "  New  York  Medical  Record," 
Feb.  II,  1899,  vol.  Lv,  p.  193. 


150 


PHYSIOLOGICAL  PREGNANCY. 


should  douching  really  reduce  morbidity?  When  vaginal  antisepsis  was  prac- 
tised as  a  routine  procedure,  it  was  asserted  that  the  upper  vagina  could  not 
be  rendered  sterile.  I  can  at  present  see  but  one  way  in  which  this  question 
can  be  answered.  If  some  of  the  experimenters  who  have  developed  the  tech- 
nique for  obtaining  the  lochial  secretion  from  the  puerperal  uterus  will  submit 
a  large  series  of  cases  to  antiseptic  vaginal  douching  before  delivery,  and  will 
then  investigate  the  bacteriology  of  the  uterine  cavity  on  the  various  puerperal 
days,  we  might  gather  some  notion  of  the  efficacy  of  vaginal  antisepsis. 

Another  method  of  some  value  might  be  the  taking  of  rectal  temperature, 
as  is  Bumm's  *  custom,  with  a  view  of  detecting  febriculas  from  slight  saprasmia, 
the  woman  having  previously  been  subjected  to  vaginal  antisepsis.  If  thirty  per 
cent,  to  sixty  per  cent,  of  the  cases  showing  elevation  of  temperature  (100.4°  F- 
in  the  rectum)  should  show  a  marked  reduction,  we  might  well  conclude  that 
vaginal  douching  should  be  practised. 

Hofmeier  (Wurzburg)  t  has  repeatedly  asserted  the  value  of  routine  prophy- 
lactic antepartum  douching,  and  credit  must  certainly 
be  given  him  for  securing  the  smallest  morbidity  and 
mortality  of  any  maternity  in  Germany.  This  ob- 
stetrician has  had  but  four  deaths  in  his  last  6000 
deliveries — a  mortality  of  but  0.06  per  cent.  It  should 
be  added  that  the  general  hygienic  conditions  at  H  of- 
meier's  clinic  are  by  no  means  favorable,  and  that  his 
cases  are  examined  by  a  very  large  number  of  stu- 
dents, candidates  for  state  examinations  and  by  mid- 
wives.     Sublimate  is  used  as  an  antiseptic. 

Lenhartz  J  states  that  of  forty  deaths  from  puer- 
peral infection  at  the  Eppendorfer  Krankenhaus, 
Hamburg,  no  less  than  twenty-two  occurred  after 
normal  spontaneous  labor.  It  seems  a  reasonable 
supposition  that  antepartum  douching  would  have 
saved  many  of  these  women.  Lenhartz  recommends 
prophylactic  douching  with  sublimate  (i  :  4000)  or 
lysol  (two  per  cent.). 

Preparation  of  the  Patient. — When  feasible  the 
bladder  and  rectum  should  be  emptied,  the  external 
genitals  scrubbed  with  soap  and  water  with  a  soft 
brush  or  cotton,  the  whole,  including  the  vulval  canal, 
rinsed  with  plain  water,  and  then  cleansed  or  irrigated 
with  I  :  2000  or  i  :  4000  sublimate  solution,  from 
above  downward. 
Preparation  of  Physician. — Care  of  the  Finger-nails. — Ragged,  unclean, 
badly  groomed  finger-nails  are  inexcusable  in  the  obstetrician,  and  certainly  pre- 
dispose to  sepsis,  since  they  cannot  readily  be  rendered  aseptic  (Fig.  188).  With 
a  few  minutes'  attention  each  morning,  one  can  keep  his  finger-nails  in  good  con- 
dition. The  shape  of  the  nail  is  largely  a  matter  of  individual  taste,  but  for 
aseptic  purposes  a  nail  with  rounded  point  will  best  serve  the  obstetrician's 
purpose,  provided  that  at  the  rounded  point  the  nail  is  not  more  than  yg-  inch 
(0.15  cm.)  in  length. 

Disinfection    of  the  Hands. — The  foundation  of  the  aseptic   method  in 

*Bumm:  "  Zeitschr.  f.  Medizinal-beamte,"  April  i,  1903. 
t  Hofmeier:  "Munch,  med.  Wochen.,"  1902,  Nos.  18,  19. 
J  Lenhartz:   "Die  septiscH.  Erkrankungen,"  Wien,  1903. 


Fig.  188. — The  Left-hand 
Finger  shows  an  Ex- 
aggeration OF  A  Badly 
Groomed  Finger-nail 
and  Cuticle  which 
Would  Favor  Sepsis 
FROM  the  Lodgment  of 
Septic  Material.  The 
Right-hand  Finger 
shows  a  Properly  Kept 
Nail  and  Cuticle. 


THE   EXAMINATION   OF   PREGNANCY. 


151 


obstetrics  rests  upon  sterilization  of   the  hands,  which  may  be   accomphshed 

in  one  of  several  ways.     It  must  be  remembered  that  when  we  refer  to  the  hand 

we  include  as  well  the  forearm  to  the  elbow,  which  in  all  cases,  especially  in 

labor  and  operative  obstetrics,  should  receive  the  same  conscientious  cleansing 

as  the  hand  and  fingers.     To  this  end 

the  coat  should  be  removed  and  the 

sleeves  rolled  up  before  the  cleansing 

process   begins.      Women   physicians 

should  have  the  sleeves  of  both  arms 

so  made  as  readily  to  permit  of  being 

rolled  back  to  the  elbow.    All  methods 

of  disinfection  should  be  preceded  by 

thorough    and    prolonged    scrubbing 

with  a  hand-brush  in  soap  and  hot 


Fig.  189. — Flattened  End  of  an  Orange 
Stick  Used  to  Push  Back  the  Cuticle 
FROM  THE  Nail. 


Fig.  190. — Edge  of  a  Towel  Used  for 
Cleaning  and  Polishing  the  Inner 
Surface  of  the  Finger-nail. 


water,  particular  attention  being  given  to  the  spaces  under  and  around  the 
nails,  which  are  to  be  kept  short  and  smooth.  About  five  minutes  should  be 
employed  in  the  scrubbing  process,  which  is  to  be  followed  by  some  form  of 
chemical  antiseptic  treatment. 

Rubber  Gloves. — I  cannot  too  strongly  urge  the  use  of  sterile  rubber  gloves, 
as  a  routine  measure  in  confinement 
cases.  No  ordinary  obstetrician, 
namely,  the  so-called  general  prac- 
titioner, and  no  physician,  surgeon 
or  obstetrician,  who  is  at  all  doubtful 
concerning  his  personal  asepsis,  is 
justified  in  attending  women  in  con- 
finement without  utilizing  this  simple 
and  effective  precaution. 

Chemical     Antiseptics.  —  The 
most    generally    employed    chemical 

antiseptics  are  carbolic  acid  and  bichloride  or  biniodide  of  mercury.  A  very 
large  number  of  other  chemicals  have  been  suggested  and  used  more  or  less, 
but  few  of  them  have  any  qualities  which  will  enable  them  to  displace  the  sub- 


FiG.   191. — Hand  Enclosed  in  Rubber 
Glove. 


152 


PHYSIOLOGICAL  PREGNANCY. 


stances  first  mentioned.  Among  those  which  have  from  time  to  time  proved 
useful  may  be  enumerated  permanganate  of  potash,  oxaUc  acid,  chlorinated  lime 
and  carbonate  of  soda,  alcohol,  creolin,  lysol,  and  hydrogen  peroxide.  Creolin 
is  not  often  used  at  present,  but  lysol,  in  a  two  per  cent,  solution,  is  employed 
to  some  extent  as  a  vaginal  douche  before  labor,  when  there  is  reason  to  believe 
that  there  is  infection  present  in  the  vagina,  and  also  as  a  solution  for  instru- 
ments. It  is  objectionable  for  the  latter  use  because  it  makes  the  instruments 
slippery,  while  this  lubricating  quality  is  somewhat  useful  when  employed  in  the 
vagina.  Bichloride  of  mercury  is  used  in  solution  for  various  purposes  in  strengths 
of  I  :  500  to  I  :  10,000,  and  the  same  is  true  of  the  biniodide.  The  tablets  which 
are  extensively  sold  are  very  convenient  and  accurate  in  making  solutions  of  these 

chemicals,  and  they  have  the  addi- 
tional advantage  that  substances 
are  combined  with  them  which  pre- 
vent the  solutions  becoming  inert 
as  a  result  of  the  affinity  of  the 
mercuric  salt  for  albuminous 
bodies.  Carbolic  acid  is  used  in 
watery  solutions,  to  which  a  little 
glycerin  has  been  added.  The 
strength  varies  from  1  :  20  to 
I  :  100.  After  the  preliminary 
scrubbing  one  of  the  following  anti- 
septic methods  should  be  em- 
ployed: 

1.  The  scrubbed  hands  and  fore- 
arms are  ( i )  rinsed  in  sterile  water ; 
(2)  immersed  for  half  a  minute  in 
alcohol  of  at  least  80  per  cent, 
strength;  and  (3)  then  in  a  i  :  1000 
or  I  :  2000  solution  of  bichloride  or 
biniodide  of  mercury,  for  from 
three  to  five  minutes.  A  scrub- 
bing-brush may  also  be  used  with 
advantage  in  these  solutions,  to 
assist  in  causing  the  antiseptic  to 
penetrate. 

2.  After  scrubbing,  the  hands 
and  forearms  are  (i)  immersed  in 
a  saturated  solution  of  potassium 
permanganate  until  they  are 
stained  a  deep  mahogany  brown; 

(2)  they  are  then  transferred  to  a  saturated  solution  of  oxalic  acid,  and  kept 
immersed  until  decolorized.  (3)  After  this  they  are  rinsed  in  sterile  water  or 
salt  solution.  This  method  is  very  efficient.  Some  writers  advise  washing  for 
three  minutes  in  a  i  :  500  bichloride  of  mercury  solution,  as  an  additional  pre- 
caution after  the  oxalic  acid  is  washed  off  (Halsted,  1899). 

3.  (i)  A  paste  is  made  by  mixing  water  with  chlorinated  lime ;  the  hands  are 
rubbed  thoroughly  with  this,  and  (2)  meanwhile  a  lump  of  sodium  carbonate 
is  picked  up  and  rubbed  in  with  the  mixture,  until  a  sensation  of  coolness  is  felt. 

(3)  A  hand-brush  is   now  used  with   the  solution   for  several   minutes,   and 

(4)  the  hands  washed  in  sterile  water  and  then  in  (5)  alcohol  or  weak  ammonia 


Fig.  192. — Opened  Vulva  in  a  Primigravida, 
Aged  Twenty-two;  Thirtieth  Week  of 
Pregnancy;  Deep  Vulval  Canal. — (From  a 
photograph  at  the  New  York  Maternity}) 


THE  EXAMINATION   OF   PREGNANCY. 


153 


water.  The  last  two  methods  are  very  efficient  and  are  commonly  used  by 
surgeons  in  operating,  but  even  after  these  precautions  cultures  from  the  deeper 
layers  of  the  skin  will  sometirnes  grow.  After  the  sterilization  of  the  hands  is 
complete,  the  obstetrician  niust  see  to  it  that  they  are  not  again  contaminated 
by  coming  in  contact  with  anything  which  has  not  been  sterilized,  between  the 
antiseptic  solution  and  the  vagina. 

Sterilized  rubber  gloves  will  be  found  useful  in  obstetrical  practice  for  making 
examinations,  especially  when  the  hands  have  recently  had  to  do  with  septic 
cases,  or  when  the  means  for  a  chemical  sterilization  are  not  at  hand.     The 
rubber  gloves  can  be  sterilized  by  boiling  (Fig.  191).     If  a  lubricant  is  necessary, 
and  it  rarely  is,  it  should  be  vaseline 
or  glycerin  which  has  been  heated  for 
five  or  ten  minutes  to  212°  F.  and 
kept  afterward  in  a  sterilized  vessel. 

Objects  of  the  Examination. — In 
the  examination  of  pregnancy  (i) 
the  actual  existence  of  pregnancy 
should  be  determined,  as  well  as  (2) 
the  period  of  gestation;  (3)  the  prob- 
able date  of  labor;  (4)  the  viability 
of  the  fetus;  (5)  the  diagnosis  of  the 
presentation,  position,  and  engage- 
ment of  the  head;  (6)  the  condition 
of  the  patient's  genital  organs,  in- 
cluding the  breasts;  (7)  the  size  of 
her  pelvis ;  and  (8)  the  obstetric  prog- 
nosis. It  is  advisable  also  at  this 
time  to  inquire  and  record  (see  chart, 
Appendix)  (i)  the  date  and  type  of 
the  last  menstruation ;  (2)  her  family 
and  personal  history,  including  de- 
gree of  parity;  (3)  the  character  of 
her  previous  pregnancies,  labors,  and 
puerperiums.  Her  nurse  or  nurses 
should  also  be  arranged  for,  and 
directions  given  regarding  the  hy- 
giene of  pregnancy  and  the  procur- 
ing of  the  mother's,  baby's,  and  ob- 
stetric outfit.  (See  Part  IV.)  Primi- 
gravidae  should  have  their  pelves 
measured  before  the  twenty-eighth 
week;  the  spines,  crests,  trochanters, 

external  and  internal  conjugates,  being  measured  as  matters  of  routine.  Should 
pelvic  deformity  exist,  more  exhaustive  measurements  should  be  taken,  and  if 
necessary  we  should  not  hesitate  to  make  an  internal  examination  under  nitrous 
oxide,  chloroform,  or  ether.  A  comparison  should  be  made  between  these  measure- 
ments and  the  weight  and  height  of  the  patient,  and  her  husband,  and  their  ages. 
The  patient's  skeleton  should  be  considered  as  to  its  character;  one  composed 
of  light  bones  has  generally  a  relatively  large  pelvic  girth,  while  the  converse 
also  holds  true.  If  the  patient  be  a  multigravida,  all  of  these  careful  measure- 
ments are  not  necessary  in  private  practice,  if  the  previous  children  have  been 
of  usual  size  and  the  labors  uneventful.     However,  the  size  of  the  fetal  head 


Fig.  193. — Opened  Vulva  in  a  Primigravida; 
Thirty-eighth  Week;  Shallow  Vulval 
Canal. —  {From  a  photograph  at  the  New  York 
Maternity.) 


154 


PHYSIOLOGICAL  PREGNANCY. 


should  be  estimated  two  weeks  before  labor  is  expected,  in  order  to  detect  any 
overgrowth  of  the  fetus.  (See  Cephalometry.)  The  examination  of  pregnancy 
can  conveniently  be  divided  into  (i)  external  or  abdominal,  and  (2)  internal  or 
vaginal. 

EXTERNAL  OR   ABDOMINAL   EXAMINATION.     DIAGNOSIS  OF    FETAL 
PRESENTATION,  POSITION,  AND    ENGAGEMENT    OF    PRE- 
SENTING   PART.     EXTERNAL    PELVIMETRY. 

The  patient  should  lie  upon  her  back  upon  the  side  of  the  bed  or  couch, 
with  the  clothing  loosened  and  the  abdomen  bare,  or  covered  only  with  one 
thickness  of  a  bed-sheet,  through  which  it  is  possible  to  make  a  satisfactory 
examination.     The  examiner  should  see  that  his  hands  are  warm,  since  the 


Fig.  194. — Location  of  the  Fetal  Back  and  Small  Parts  by  External  Palpation. 
The  left  hand  displaces  the  fetus  to  the  left  for  locating  the  dorsal  plane. — {From 
a  photograph  taken  at  the  Emergency  Hospital.) 


contact  of  a  cold  hand  with  the  abdominal  wall  is  apt  to  excite  reflex  contractions 
of  the  abdominal  muscles,  and  even  in  the  uterus.  Moderate  flexion  of  the 
thighs  will  often  assist  in  relaxing  the  abdominal  muscles,  and  this  position 
can  often  be  used  to  advantage.  The  bladder  and  rectum  should  have  been 
emptied  recently.  We  should  ascertain  as  much  as  possible  at  the  first  exam- 
ination, and,  in  order  that  nothing  be  overlooked,  we  ought  to  follow  some 
definite  routine  order  of  examination,  as  in  the  case  of  the  internal  examination 


THE  EXAMINATION  OF  PREGNANCY. 


155 


of  pregnancy  (see  page  167)  and  labor  (see  Labor).  We  should  also  accustom 
ourselves  to  palpate  with  the  left  as  well  as  the  right  hand.  The  order  of 
examination  here  recommended  is:  (i)  Determination  of  general  conditions. 
(2)  Location  of  fetal  back,  and  small  parts.  (3)  Palpation  of  the  lower  fetal 
pole.  (4)  Palpation  of  the  upper  fetal  pole.  (5)  Location  of  the  cephalic 
prominence.  (6)  Deep  pelvic  palpation.  (7)  Locating  anterior  shoulder.  (8) 
Palpation  in  breech  presentation.  (9)  Palpation  in  shoulder  presentation. 
(10)  Location  of  the  fetal  heart.  (11)  External  pelvimetry.  Most  of  the 
methods  of  abdominal  palpation  can  be  carried  out  while  the  examiner  sits 
at  the  bedside,  facing  the  patient's  abdomen. 


Fig.    195. — Palpating   the   Lower   Fetal   Pole   by   External   Palpation. — (Front   a 
photograph  taken  at  the  Emergency  Hospital.) 


I.  General  Conditions. — (i)  The  general  condition  of  the  patient  should 
first  be  observed,  and  evidences  of  blood  changes,  pulmonary,  cardiac,  renal, 
syphilitic,  or  tuberculous  disease  noted;  (2)  the  breasts  and  nipples  are  to  be 
inspected  for  lacteal  capacity  and  evidences  of  previous  inflammation  in  the 
former,  and  for  flatness,  inversion,  fissure,  or  erosion  of  the  latter.  We  pass 
next  to  the  abdomen  and  determine  (3)  the  direction  of  the  uterine  axis,  detecting 
any  excessive  right  or  left  lateral  obliquity  or  other  displacement,  the  result  of 
previous  inflammations  or  operation,  and  (4)  the  thickness  and  pendulous 
condition  of  the  abdominal  walls.  We  should  then  determine  by  abdominal 
palpation  the  general  shape  and  size  of  the  uterus;  the  relation  of  the  fundus 
to  the  umbilicus  and  ensiform  cartilage;  the  size  of  the  fetus,  and  its  relation 


156 


PHYSIOLOGICAL   PREGNANCY. 


to  the  amount  of  liquor  amnii,  and  whether  the  fetus  lies  vertically,  trans- 
versely, or  obliquely  in  the  uterus.  This  is  accomplished  by  placing  the  palms 
of  the  hands  one  on  each  side  of  the  abdomen,  and  sliding  them  evenly  and 
gently  upward  and  downward  over  the  entire  pregnant  uterus,  from  the  fundus 
to  the  pubis  and  back  again  to  the  fundus,  at  the  same  time,  gently  and  without 
much  pressure,  palpating  the  whole  maternal  abdomen  with  the  finger-tips 
(Figs.  195  to  201). 

2.  Location  of  Fetal  Back  and  Small  Parts. — The  next  point  to  be  made 
out  is  the  location  of  the  child's  back;  this  can  usually  be  done  by  palpating 
the  whole  maternal  abdomen  with  the  tips  of  the  fingers,  gently  and  without 


Fig.    196.— Palpating   the    Upper   Fetal   Pole    by   External   Palpation. — (From   a 
photograph  taken  at  the  Emergency  Hospital.) 


much  pressure.  Stronger  pressure  may  be  necessary  to  ascertain  the  amount 
of  resistance,  mobility,  etc.,  but  it  should  be  remembered  that  strong  pressure 
blunts  the  tactile  sensibility  of  the  ends  of  the  fingers.  The  small  parts  by 
this  method  will  be  felt  as  small  rounded  knobs,  more  or  less  movable.  If  the 
examiner  will  steady  the  fetus  in  its  long  axis,  and  exert  some  pressure  upon 
the  upper  pole,  the  dorsal  convexity  will  be  considerably  increased,  and  therefore 
more  easily  palpated.  Another  method  is  to  apply  moderate  deep  pressure 
with  the  palm  of  the  hand  on  the  middle  of  the  abdomen.  This  displaces  the 
fetus  toward  the  side  to  which  its  back  is  turned,  and  while  the  pressure  is  main- 
tained with  one  hand  the  examination  may  be  made  satisfactorily  with  the 
other  (Fig.  195).     In  order  to  make  out  whether  the  back  of  the  fetus  is  turned 


THE  EXAMINATION  OF  PREGNANCY. 


157 


toward  the  back  or  front  of  the  mother,  it  is  to  be  remembered  that  the  fetal 
back  offers  a  broad,  smooth  convex  surface  from  end  to  end,  while  the  lateral 
aspect  is  not  convex  from  end  to  end,  is  narrower,  and  has  a  deep  sulcus  be- 
tween head  and  pelvis.  T-he  small  parts  on  one  side  indicate  that  the  back 
is  on  the  other,  except  in  the  case  of  twins.  If  small  parts  can  be  felt  beyond 
either  end  of  the  fetus,  the  presentation  is  pretty  certainly  a  breech.  Certain 
conditions  may,  when  present,  make  this  part  of  the  examination  difficult  or 
uncertain.  A  large  amount  of  abdominal  fat,  hydramnios,  and  a  rigidly  con- 
tracted uterus,  are  some  of  these  conditions. 

3.  Palpation  of  the  Lower  Fetal  Pole. — The  hands  of  the  examiner  are  placed 


Fig.  197. — Locating  the  Cephalic  Prominence. in  Vertex  Presentation  by  External 
Palpation. — (Front  a  photograph  taken  at  the  Emergency  Hospital.) 


flat  upon  the  sides  of  the  abdomen,  with  the  palms  toward  each  other,  and 
the  fingers  toward  the  feet  of  the  patient,  and  resting  a  little  above  Poupart's 
ligament  (Fig.  195).  When  the  hands  are  passed  toward  each  other  and  also 
toward  the  cavity  of  the  maternal  pelvis,  it  is  usually  possible  to  catch  quickly 
the  fetal  pole,  and  to  manipulate  it.  The  first  point  to  determine,  when  the 
pole  is  found,  is  whether  it  is  head  or  breech.  The  head  is  large,  hard,  and 
globular,  and  separated  from  the  trunk  by  the  constriction  of  the  neck;  and  it 
is,  furthermore,  the  only  part  of  the  fetus  which  sinks  into  the  maternal  pelvis 
before  labor.  The  breech  always  lies  above  the  excavation  of  the  pelvis  until 
labor  begins.  When  either  fetal  pole  is  found  in  an  iliac  fossa,  the  presentation 
will  be  transverse. 


158 


PHYSIOLOGICAL   PREGNANCY. 


4.  Palpation  of  the  Upper  Fetal  Pole. — To  accomplish  this  satisfactorily, 
the  position  of  the  hands  is  in  the  opposite  direction  from  that  just  described,  the 
palms  being  placed  facing  each  other  on  the  upper  part  of  the  abdomen,  with 
the  fingers  toward  the  patient's  head  (Fig.  196).  The  head  when  found  in  the 
upper  segment  of  the  uterus  can  be  subjected  to  ballottement,  and  otherwise 
has  the  characteristics  which  have  been  mentioned  (Fig.  200).  The  breech 
in  the  upper  segment  is  less  mobile,  more  voluminous,  and  softer  than  the 
head  (Fig.  196). 

5.  Location  of  the  Cephalic  Prominence. — (i)  The  hand  is  pressed  trans- 
versely across  the  maternal  abdomen,  just  above  the  symphysis,  and  the  head 


Fig.  198. — Deep  Pelvic  Palpation  to  Determine  the  Amount  of  Engagement  op 
THE  Presenting  Part  by  External  Palpation. — {From  a  photograph  taken  at  the 
Emergency  Hospital.) 


thus  grasped  and  palpated  (Fig.  197).  The  occipital  side  is  that  at  which 
the  hand  sinks  deepest  into  the  pelvis;  since  the  occiput  itself  is  the  part  of 
the  head  which,  as  a  rule,  is  deepest  in  this  cavity.  The  greatest  prominence 
at  the  brim  is,  therefore,  the  forehead,  most  marked  in  the  occipito-posterior 
position.  (2)  The  right  or  left  hand,  with  thumb  and  fingers  separated  as  far 
as  possible,  grasps  the  fetal  head  just  above  the  pelvic  inlet  (Fig.  197).  Since 
the  head  in  primigravidae  is  usually  partially  engaged  in  the  pelvic  inlet,  it  is 
advisable  to  direct  the  thumb  and  finger-tips  downward  toward  the  pelvic 
cavity.  In  multigravidse,  by  reason  of  the  rather  high  situation  of  the  head 
the  thumb  and  finger-tips  are  held  more  horizontally.      In  the  latter  case  we 


THE  EXAMINATION   OF   PREGNANCY, 


159 


can  assist  in  the  manoeuver  by  steadying  the  fundus  with  the  disengaged  hand. 
The  head  feels  hard  and  ball-Hke  and  can  usually  be  moved  from  side  to  side. 
The  breech  appears  soft  and  irregular.  In  pelvic  presentation  the  same  method 
can  be  applied  to  the  head  lying  in  the  fundus  (Fig.  197).  In  shoulder  presenta- 
tion, no  definite  presenting  part  being  found  at  the  pelvic  inlet,  the  head  is 
sought  for  by  gently  palpating  with  short  finger-strokes  in  one  or  the  other  side 
of  the  uterus  (Fig.  201 ).  It  can  then  be  grasped  in  the  same  manner  as  above, 
and  the  manoeuver  assisted  by  steadying  the  breech  with  the  disengaged  hand. 
6.  Deep  Pelvic  Palpation. — In  primigravidae  when  the  head  is  engaged  in 
the  pelvis,   and  in  both  primiparae  and  multiparas    when  the  same  condition 


Fig.  199, — Locating  the  Anterior  Shoulder  by  External  Palpation.  Right  hand 
depresses  and  raises  fundus,  while  the  left  palpates  for  the  shoulder. —  {From  a  photo- 
graph taken  at  the  Emergency  Hospital.) 


obtains,  the  method  of  palpating  the  cephalic  extremity  shown  in  Fig.  198  is 
most  useful,  especially  during  labor.  Moderate  flexion  of  the  thighs,  approxi- 
mation of  the  heels,  and  separation  of  the  knees  greatly  assists  in  relaxing  the 
anterior  abdominal  walls.  As  pictured  in  Fig.  198,  the  examiner  stands  at 
the  side  of  the  bed,  facing  the  patient's  feet.  The  palms  of  the  hands  are 
placed  on  both  sides  of  the  lower  uterine  segment,  and  the  finger-tips  of 
both  hands  are  made  to  enter  the  pelvic  cavity  slowly  and  gently,  alongside 
of  the  head,  between  it  and  the  pelvic  walls.  As  in  Fig.  197,  but  more  satis- 
factorily, the  head  when  engaged  in  the  pelvis  can  be  felt  as  a  hard,  oval  body 
occupying  the  latter;  the  more  prominent  forehead,  on  one  side,  being  readily 


160 


PHYSIOLOGICAL   PREGNANCY. 


distinguished  from  the  less  prominent  occiput,  or  nape  of  the  neck,  on  the 
other.  The  forehead  is  especially  prominent  in  occiput  posterior  positions 
(Fig.  198).  We  have  no  more  valuable  method  of  determining  bregma, 
brow,  and  face  presentations  before  dilatation  of  the  os,  than  that  by  deep  pelvic 
palpation.  In  bregma  presentation  incomplete  flexions  of  the  occiput  and 
forehead  are  about  equally  prominent;  in  brow  presentations  the  occiput  is 
more  in  evidence,  while  in  face  presentations  it  is  the  most  prominent  part 
of  the  fetal  head  to  be  palpated. 

7.  Location  of  the  Anterior  Shoulder. — One  hand  is  placed  above  the  uterus 
upon  the  fundus,  so  as  to  steady  the  organ  and  press  it  into  the  pelvis.     A¥ith 


Fig.  200. ^Locating  the  Cephalic  Extremity  of  the  Fetus  in  Breech  Presentation 
BY  External  Palpation. — (From  a  photograph  taken  at  the  Emergency  Hospital.) 


the  other  hand  the  anterior  shoulder  can  be  recognized  as  a  rounded  prominence, 
which  when  on  the  left  of  the  median  line,  indicates  a  left  fetal  position,  and 
when  on  the  right,  a  right  fetal  position.  When  the  shoulder  is  less  than  two 
inches  from  the  median  line,  the  fetal  position  will  be  anterior;  when  more 
than  two  inches  away,  posterior  (Fig.  199). 

8.  Palpation  in  Breech  Presentation  (Fig.  200). — The  flexed  band  is  pressed 
transversely  across  the  maternal  abdomen  just  at  or  above  the  umbilicus  and  the 
head  grasped  and  palpated  (Fig.  200).  Or  we  can  proceed  as  in  palpation  of  the 
upper  fetal  pole  (Fig.  196).  The  anterior  shoulder  (Fig.  199),  the  dorsal  plane, 
and  small  parts  (Fig.  195)  are  palpated  practically  as  in  head  presentations. 


THE  EXAMINATION   OF  PREGNANCY. 


161 


9.  Palpation  in  Shoulder  Presentation  (Fig.  201). — The  same  general  prin- 
ciples apply  here  as  in  head  and  pelvic  presentations. 

10.  Location  of  the  Fetal  Heart  (Fig.  171). — This  may  be  accomplished 
with  the  stethoscope,  with  the  phonendoscope,  or  by  the  ear  alone.  The  abdom- 
inal wall  should  be  pressed  against  the  uterine  tumor,  since  sound  is  best  trans- 
mitted through  a  homogeneous  soHd.  This  is  best  accomplished  by  pressing 
the  fundus  with  one  hand,  and  directing  the  uterus  downward  and  forward 
(Fig.  171).  It  is  advisable  to  direct  this  pressure  in  such  a  manner  as  to  bring 
simultaneously  the  dorsal  surface  of  the  fetus  as  nearly  as  possible  under  the 


'•/ 


Fig.  201.— Locating  the  Cephalic  and  Podalic  Extremities  of  the  Fetus  in  Shoulder 
Presentation  by  External  Palpation.  The  left  hand  grasps  the  head  and  the 
right  the  breech. — (From  a  photograph  taken  at  the  Emergency  Hospital.) 


stethoscope.  The  sounds  resemble  the  ticking  of  a  watch  under  a  pillow,  and 
vary  from  130  to  140  per  minute,  being  about  twice  as  frequent  as  those  of  the 
healthy  adult  heart.  Active  movement  on  the  part  of  the  fetus  increases  the 
fetal  heart-rate.  If  the  organ  is  located  on  the  left, — that  is,  if  the  point  of 
greatest  intensity  of  the  heart  sounds  is  on  the  left  of  the  median  line, — the 
presentation  is  left;  if  on  the  right,  the  presentation  corresponds.  If  the  heart 
is  located  above  the  umbilicus,  the  presentation  is  pelvic;  if  below,  the  head 
will  present.  Twins  show  naturally  two  hearts  of  different  rates,  and  the  sex 
can  sometimes  be  guessed  at  by  remembering  that  a  persistent  fetal  heart  rate 
under  120  indieates  a  boy;  and  over  that  a  girl.  In  certain  dorso-posterior 
11 


162 


PHYSIOLOGICAL   PREGNANCY. 


positions,  and  in  some  cases  of  hydramnios,  it  is  occasionally  impossible  to 
hear  the  fetal  heart. 

EXTERNAL  PELVIMETRY. 
In  taking  the  external  pelvic  measurements  the  pelvimeter  and  tape-measure 
are  necessary.  Two  very  good  instruments  in  common  use  are  the  pelvimeters  of 
Baudelocque  (Fig.  203)  and  of  Schultze  (Fig.  202).  The  former  must  be  used  with 
caution  on  account  of  the  spring  of  the  metallic  arms.  The  modification  of  the 
Baudelocque  pelvimeter,  elliptical  in  shape,  occasionally  seen  at  the  instrument- 
makers,  has  even  greater  spring  than  the  original,  and  should  be  avoided  if  accur- 
ate results  are  desired.  The  Schultze  pelvimeter  is  of  a  shape  which  gives  great 
firmness,  and  is  convenient  to  carry  in  the  pocket  or  obstetric  bag.  In  use  the  arms 
of  the  pelvimeter  are  separated,  a  rod  being  taken  in  each  hand,  with  an  index- 
finger  on  each  knob.     The  knobs  are  then  placed  on  the  two  selected  points, 

fixed  in  position,  the  screw  near  the  handle  is 
tightened  by  an  assistant,  and  the  distance 
between  the  two  points  is  read  off  on  the  scale 
attached  to  the  instrument  (Fig.  203).  The 
patient  should  be  dressed  as  for  bed,  and  placed 
first  in  the  dorsal  position,  upon  the  side  of  the 
bed  or  lounge.  The  physician  standing  at  her 
right  side,  and  holding  an  arm  of  the  instru- 
ment with  the  thumb  and  fingers  of  each  hand 
near  the  points,  applies  the  latter  to  the  outer 
edge  of  the  anterior  superior  iliac  spines,  and 
notes  the  diameter  thus  gained  (Fig.  203).  He 
then  pushes  the  points  backward  and  forward 
along  the  outer  edge  of  the  iliac  crest,  and  notes 
the  greatest  diameter  which  can  in  this  way  be 
obtained.  The  woman  then  turns  on  her  side, 
or  abdomen,  and  the  points  of  the  pelvimeter 
are  placed  on  the  posterior  superior  iliac  spines, 
which  are  marked  by  well-defined  dimples, 
and  the  distance  between  these  is  noted.  The 
oblique  diameter  is  obtained  by  placing  one  of 
the  points  upon  the  posterior  superior  iliac 
spine,  and  the  other  upon  the  anterior  superior 
iliac  spine  of  the  opposite  side.  The  external 
conjugate  is  obtained  while  the  patient  lies  on  her  left  side  or  stands  in  the 
erect  position.  One  point  is  placed  in  the  depression  just  below  the  spine  of 
the  last  lumbar  vertebra,  while  the  other  is  placed  upon  the  middle  of  the 
upper  anterior  border  of  the  symphysis  pubis.  The  distance  between  the 
femoral  trochanters  may  be  obtained  by  placing  each  point  as  nearly  as 
possible  upon  the  most  projecting  part  of  each  greater  trochanter.  This  last 
is  an  unimportant  diameter.  In  external  pelvimetry  we  rely  upon  the  fol- 
lowing twelve  measurements;  the  first  four  of  which  are  most  commonly 
used:  (i)  Interspinous.  (2)  Intercristal.  (3)  Between  the  great  trochanters. 
(4)  The  external  conjugate,  or  Baudelocque's  diameter.  (5)  Right  oblique 
diameter.  (6)  Left  obUque  diameter.  (7)  Between  the  posterior  superior 
iliac  spines.  (8)  Between  the  tub  era  ischii.  (9)  Transverse  diameter  of  outlet. 
(10)  Antero-posterior  diameter  of  outlet.  (11)  Length  of  the  symphysis. 
(12)  Circumference  of  the  pelvis.     (13)   True  conjugate  measured  externally. 


Fig.     202. — Schultze's 

METER. 


Pelvi- 


THE  EXAMINATION  OF  PREGNANCY. 


163 


1.  Interspinous  Diameter  (Fig.  203). — This  is  the  widest  distance  between 
the  anterior  superior  ihac  spines,  and  is  measured  by  placing  the  points  of  the 
pelvimeter  upon  the  external  surfaces  of  the  spines,  at  the  insertion  of  the  sar- 
torius  muscles  (Fig.  203).  In  normal  pelves  this  measurement  varies  from 
9^  to  10^  inches  (24.1  to  26.7  cm.). 

2.  Intercristal  Diameter  (Figs.   203  and  204). — This  is  the  widest  interval 


A/f/erior 


Fig.  203. — Measuring  the  Interspinal  Diameter  with  the  Baudelocqub  Pelvimeter. 


between  the  iliac  crests,  and  is  measured  between  the  most  prominent  portions 
(Fig.  204).  In  normal  pelves  this  diameter  varies  from  10^  to  11^  inches  (26.7 
to  29.1  cm.). 

3.  Between  the  Great  Trochanters  (Fig.  209). — This  diameter  is  the  greatest 
distance  between  the  external  surfaces  of  the  great  trochanters  of  the  femora. 
In  normal  conditions  it  measures  12.4  inches  (31  cm.),  but  may  even  be  ii^ 


164 


PHYSIOLOGICAL   PREGNANCY. 


inches  (29.1  cm.),  without  indicating  pelvic  contraction.     Because  of  variations 
in  the  size  of  the  femoral  head,  this  diameter  is  the  most  unreliable  one  of  those 

here  mentioned. 

4.  The  External  Con- 
,,:  jugate;  Baudelocque's  Di- 

n;  i  ameter(Figs.2o6  and  207). 

— This  is  measured  from 
the  depression  just  below 
the  spine  of  the  last  lum- 
bar vertebra,  which  is 
about  one  inch  above  the 
posterior  interspinous  di- 
ameter, to  the  point  on 
the  skin  of  the  mons  ven- 
eris in  front  of  the  upper 
external  edge  of  the  sym- 
physis pubis.  In  normal 
cases  it  measures  8  inches 
(20.3  cm.).  As  a  clinical 
index  of  contracted  pelvis 
this  diameter  is  unreliable. 
According  to  Jewett,  how- 
ever, when  the  external 
conjugate  is  at  or  below  6 
inches  (15.2  cm.),  or  even 
below  6^  inches  (15.8  cm.), 
the  pelvis  is  invariably 
contracted;  between  6^ 
inches  (15.8  cm.)  and  8 
inches  (20.3  cm.)  the  amount  of  contraction  is  very  uncertain,  and  must  be 
settled  by  internal  measurements;  at  or  above  8  inches  (20.3  cm.)  the  pelvis  is 
almost  sure  to  have  ample  room.  A  certain  relationship  is  said  to  exist  between 
the  lengths  of  the  ex- 
ternal and  internal 
conjugates  ;  such 

marked  variations, 
however,  occur  be- 
tween the  two  that 
the  external  can 
never  be  relied  upon 
as  an  exact  clinical 
index  of  the  internal. 
Litzmann  measured 
the  external  conju- 
gate during  Hfe,  and 
the  internal  or  true 
conjugate  post  mor- 
tem in  30  cases,  and 

found  that  there  was  an  average  difference  between  the  two  of  3!  inches  (9.5  cm.). 
In  the  entire  30  cases,  there  were  variations  from  2f  inches  (7  cm.)  to  4^f  inches 
(12.5  cm.). 

5  and  6.  Right  and  Left  External  Obliques  (Fig.   205). — The  right  external 


Fig.  204. — Position  of  the  Points  of  the  Pelvimeter 
FOR  Measuring  the  Intercristal  and  Bitrochanteric 
Diameters  of  the  Pelvis. 


Sapfr/or 
Spwe 


Fig.  205. — Position  of  the  Points  of  the  Pelvimeter  for 
Measuring  the  Right  External  Oblique  Diameter  of  the 
Pelvis. 


THE  EXAMINATION  OF   PREGNANCY. 


165 


oblique  is  measured  from  the  right  posterior  superior  spine  of  the  iHum  to  the 
left  anterior  superior  spine,  and  measures  8|  inches  (22  cm.).  The  left  external 
oblique  is  the  distance  from' the  left  posterior  superior  spine  of  the  ilium  to  the 
right  anterior  superior  spine,  and  measures  also  8|  inches  (22  cm.).  These 
right  and  left  oblique  diameters  should  be  equal  or  nearly  so.  In  obliquely 
contracted  pelves,  as  the 
single  oblique  pelvis  of 
Naegele,  a  considerable 
difference  may  be  present. 
In  such  pelves  several 
other  oblique  measure- 
ments are  of  value,  in  order 
to  determine  differences 
between  the  two  lateral 
halves  of  the  pelvis,  al- 
though in  these  cases, 
more  than  in  any  other,  an 
external  examination  is 
necessary  to  detect  the  ex- 
act degree  of  deformit3^ 
Three  additional  measure- 
ments are:  (i)  From  the 
posterior  superior  spine  of 
one  side  to  the  tuber  ischii 
of  the  other.  (2)  From  the 
spine  of  the  last  lumbar 
vertebra  to  the  anterior 
superior  iliac  spines  of  both 
sides.  (3)  From  the  pos- 
terior superior  spine  of  one 
side  to  the  great  trochanter 
of  the  opposite  side.  (4) 
From  the  lower  margin  of 
the  symphysis  to  the  pos- 
terior superior  iliac  spines. 
(5)  From  the  middle  line 
of  the  back  to  both  pos- 
terior superior  iliac  spines. 

7.  Between  the  Poste- 
rior Superior  Iliac  Spines. — 
This  is  measured  from  the 
outer  surfaces  of  these 
spines,  and  equals  norm- 
ally 3|-  inches  (9.8  cm.). 

9.  Transverse  Diameter 
of  the  Outlet  (Fig.  210). — 

This  diameter  is  rarely  referred  to,  and  less  often  taken,  but  it  is  of  great 
value  in  showing  contraction  at  the  pelvic  outlet  in  kyphotic  and  funnel- 
shaped  pelves.  With  the  patient  in  the  lithotomy  position,  the  palmar  sur- 
faces of  the  index-fingers  are  pressed  firmly  against  the  inner  borders  of  the 
tuber  ischii,  and  an  assistant  then  measures  the  diameter  with  the  points  of  the 
pelvimeter  placed  on  the  index-fingers,  close  to  the  ischial  bones  (Fig.    209). 


Fig.  206. — Measuring  the.  External  Conjugate  Diam- 
eter OF  the  Pelvic  Inlet.  Diameter  of  Baude- 
locque.     Baudelocque  Pelvimeter. 


166 


PHYSIOLOGICAL  PREGNANCY. 


Normally  this  diameter  is  4^  inches  (11  cm.).  The  transverse  diameter  of 
the  outlet  may  be  measured  with  equal  facility  by  determining  the  distance 
between  the  ischial  tuberosities.  The  site  of  the  latter  is  located  by  the 
points  at  which  a  horizontal  line  touching  the  anterior  margin  of  the  anus 
comes  in  contact  with  the  folds  of  the  thigh.  The  knobs  of  the  pelvimeter 
are  applied  at  these  points,  the  shanks  of  the  instrument  having  previously 
been  overlapped,  and  pressed  firmly  against  the  subjacent  bones.  The  meas- 
urement thus  obtained  is  normally  4^  inches  (11.43  cm.).  There  should  be 
allowed  for  the  soft  parts  about  \  inch  (0.635  cm.),  varying  with  the  thickness  of 
the  nates.  The  true  transverse  diameter  of  the  outlet  is  therefore  4^  inches 
(11  cm.). 

10.  Antero-posterior  Diameter  of  the  Outlet. — The  woman  is  placed  on  her 

side  and  the  examiner  introduces  his 
index-finger  into  the  vagina,  with 
the  thumb  over  the  region,  of  the 
coccyx.  By  moving  the  latter  bone 
back  and  forth,  the  location  of  the 
sacro-coccygeal  joint  is  determined, 
and  a  pencil  mark  is  made  upon  the 
superjacent  skin.  One  button  of 
the  pelvimeter  is  applied  over  this 
mark,  while  the  other  rests  within 
the  vulva,  and  upon  the  lower  bor- 
der of  the  symphysis.  The  straight 
or  antero-posterior  diameter  of  the 
outlet  is  thus  determined,  and  is 
normally  5  inches  (12.5  cm.) .  About 
^  inch  (1.5  cm.)  must  be  subtracted 
from  the  thickness  of  the  coccyx  and 
soft  parts  to  obtain  the  actual  or 
net  measurement.  The  preceding 
method  is  known  as  Breisky's,  and 
is  endorsed  by  Skutsch.  This  diam- 
eter can  usually  more  readily  be 
measured  directly  with  the  fingers 
internally  (Fig.  208). 

II.  Length  of  the  Symphysis  (Fig. 
213). — This  is  important  in  determ- 
ining the  depth  of  the  true  pelvis, 
and  in  assisting  in  the  estimation  of 
the  true  from  the  diagonal  conjugate.  It  is  measured  with  a  pelvimeter  by  press- 
ing one  point  closely  down  upon  the  center  of  the  upper  border  of  the  symphysis, 
and  the  other  point  against  the  center  of  the  subpubic  ligament.  It  can  also 
be  estimated  with  the  fingers  (Fig.  213). 

12.  External  Circumference  of  the  Pelvis. — This  is  measured  with  the  tape- 
measure  over  the  middle  of  the  symphysis,  just  below  the  iliac  crests,  and  across 
the  middle  of  the  sacrum,  and  is  usually  about  35^  inches  (88.75  cm.). 

13.  The  True  Conjugate  Measured  Externally. — In  thin,  non-pregnant  women, 
and  in  the  early  months  of  gestation,  the  true  conjugate  may  occasionally  be 
estimated  directly  from  without,  by  placing  the  palmar  surface  of  the  hand 
upon  the  hypogastrium,  and  pressing  backward  until  the  tips  of  the  fingers  reach 
the  promontory.     The  hand  is  then  marked  over  the  pubes  with  a  finger-nail 


Fig.  207. — Point  (x)  Below  the  Spine  of  the 
Last  Lumbar  Vertebra  used  to  Indicate 
the  Posterior  Extremity  of  the  Exter- 
nal Conjugate  of  the  Pelvic  Inlet. 


THE  EXAMINATION   OF  PREGNANCY.  167 

of  the  disengaged  hand,  and  after  allowing  for  the  thickness  of  the  abdominal 
walls  and  pubes,  the  estimate  is  made.  The  method  is  of  little  practical  value. 
A  graduated  rod  with  a  blunt  surface  for  pressing  against  the  sacral  promontory 
may  be  substituted  for  the- hand. 

These  external  measurements  are  not  trustworthy,  since  errors  of  as  much 
as  two  inches  may  occur.  They  rather  point  out  the  general  shape  of  the 
pelvis  and  not  the  exact  pelvic  capacity.  Baudelocque's  conclusion  that  the 
external  conjugate  minus  from  2|  to  5  inches  (7  to  12.5  cm.)  equals  the  internal 
true  conjugate  is  now  known  to  be  untrustworthy.  Of  the  above  the  diam- 
eters of  the  most  practical  importance  are  the  (i)  interspinal,  (2)  intercristal, 
(3)  external  conjugate,  (4)  transverse  of  outlet,  and  (5)  antero-posterior  of 
outlet.  A  marked  diminution  in  the  interspinal  and  the  intercristal  diameters 
leads  to  the  suspicion  of  a  transversely  contracted  pelvis.  If  the  intercristal 
diameter  is  no  greater  than  the  interspinal,  or  if  it  is  less,  the  pelvis  is  probably 
rachitic.  A  difEerence  in  the  lateral  halves  of  the  pelvis  is  shown  by  a  difference 
in  the  oblique  diameters;  while  a  notable  diminution  in  the  external  conjugate 
shows  that  we  have  to  deal  with  a  flattened  pelvis.  Unlike  the  case  of  the 
true  conjugate,  it  is  not  safe  to  make  inferences  as  to  the  length  of  the  internal 
transverse  diameter  of  the  lesser  pelvis,  from  these  external  measurements, 
because  there  are  too  many  opportunities  for  disparities  in  the  shape  and  size 
of  the  ilia.  The  nearest  approximation  to  a  rule,  which,  however,  holds  good 
in  not  more  than  fifty  per  cent,  of  cases,  is  that  the  interspinous  line  is  twice 
as  long  as  the  transverse  diameter  of  the  lesser  pelvis.  These  external  meas- 
urements, however,  have  some  value  in  other  directions.  Thus,  if  the  spine 
and  crest  measurements  exhibit  little  or  no  difference,  the  pelvis  in  question 
is  probably  rachitic.  The  external  measurements  should  always  be  compared, 
for  if  each  has  the  normal  length,  the  lesser  pelvis  should  be  regarded  as  nor- 
mal. But  if  the  interspinous  line  is  as  long  as  the  intercristal,  or  longer,  the 
external  conjugate  is  unnaturally  short,  and  these  disparities  indicate  the  exist- 
ence of  a  fiat,  rachitic  pelvis.  Again,  if  the  three  external  measurements  are 
in  the  normal  proportion  to  one  another,  but  are  all  unnaturally  short,  they 
indicate  the  existence  of  a  generally  contracted  pelvis,  the  most  common 
variety  in  the  United  States. 

INTERNAL    OR   VAGINAL    EXAMINATION.     INTERNAL    PELVIMETRY. 

An  internal  pelvic  examination  is  imperative  in  all  primigravidse,  and  in 
others  upon  whom  the  least  suspicion  of  pelvic  deformity  rests.  The  same 
care  in  the  preparation  of  the  patient  and  of  the  physician's  hands  should  be 
taken  at  this  time  as  in  internal  examinations  during  labor. 

Objects  of  the  Examination. — In  the  internal  or  vaginal  examinations  we 
strive  (i)  to  confirm  the  findings  of  the  external  examination  in  regard  to  (a) 
the  actual  existence  of  pregnancy;  (6)  the  period  of  gestation;  {c)  the  probable 
date  of  labor;  (d)  the  viability  of  the  fetus;  {e)  the  presentation,  position, 
and  engagement  of  the  head.  (2)  In  addition,  we  seek  information  as  to  the 
conditions  of  the  soft  parts,  as  to  congenital  defects,  pathological  growths  which 
may  obstruct  or  complicate  labor,  or  injuries  resulting  from  previous  deliveries. 
(3)  The  possibility  of  a  placenta  praevia  should  always  be  kept  in  mind.  (4) 
The  size  of  the  pelvis  should  be  estimated,  and  (5)  the  obstetric  diagnosis  con- 
firmed and  completed. 


168  PHYSIOLOGICAL  PREGNANCY. 


INTERNAL   PELVIMETRY. 

For  internal  pelvimetry  many  instruments  have  been  devised,  but  the  best 
of  all  is  the  educated  hand.  AVe  have,  therefore,  manual  and  instrumental 
pelvimetry.  After  the  usual  disinfection  of  the  vulva,  and  of  the  hands  and 
arms  of  the  physician,  the  patient  is  placed  in  the  lithotomy  position,  with 
the  hips  projecting  well  over  the  edge  of  the  bed  or  table.  The  first  and  second 
fingers  are  then  introduced  into  the  vagina  and  passed  well  upward  toward 
the  promontory  of  the  sacrum.  With  these  two  fingers  the  general  conforma- 
tion and  capacity  of  the  pelvis,  the  pelvic  inclination,  the  depth,  inclination, 
and  thickness  of  the  symphysis  pubis,  the  shape  and  curve  of  the  sacrum,  the 
flexibility  of  the  coccyx,  and,  with  the  assistance  of  the  external  pressure  upon 
the  fundus,  any  marked  disproportion  between  the  fetal  head  and  pelvis,  can 
be  determined  (Fig.  226).  Several  internal  pelvic  diameters  will  demand 
measurement  in  cases  of  suspected  deformity,  although  usually  the  diagonal 
and  true  conjugates  are  a  sufficient  clinical  index  of  the  pelvic  capacity.  These 
diameters  are:  (i)  the  sacro-pubic;  (2)  the  pubo-coccygeal ;  (3)  the  transverse 
diameter  of  the  outlet;  (4)  the  diagonal  conjugate;  (5)  the  true  conjugate; 
(6)  the  transverse  diameter  of  the  inlet. 

1.  The  Sacro-pubic  Diameter  (Fig.  208). — With  two  fingers  in  the  vagina,  the 
tip  of  the  second  finger  seeks  and  presses  firmly  against  the  sacro-coccygeal 
joint,  and  the  radial  edge  of  the  hand  is  brought  up  firmly  against  the  subpubic 
ligament.  A  finger-nail  of  the  other  hand  then  marks  the  point  of  junction 
at  the  apex  of  the  pubic  arch  (Fig.  208).  The  vaginal  fingers  are  now  with- 
drawn, and  the  distance  between  the  two  points  of  contact  is  measured  with 
a  pelvimeter  or  tape-measure.  Normally  this  diameter  measures  4^  inches 
(11. 5  cm.). 

2.  The  Pubo-coccygeal  Diameter. — This  is  measured  in  the  same  manner  as  the 
above,  but  from  the  subpubic  ligament  to  the  tip  of  the  coccyx.  In  anterior 
positions  of  the  coccyx  this  diameter  is  about  4-2-  inches  (11. 5  cm.),  but  recession 
during  expulsion  of  the  head  may  readily  increase  the  diameter  to  5^  inches 
(14  cm.). 

3.  Transverse  Diameter  of  the  Outlet. — This  has  been  described  under 
external  pelvimetry  (page  162,  Fig.  210).  During  labor,  or  under  partial 
anesthesia,  this  diameter  can  be  estimated  by  pushing  the  half-fist  between 
the  ischial  tuberosities  and  partly  into  the  vaginal  orifice.  The  width  of  the 
four  fingers  or  knuckles  is  then  compared  with  the  bisischial  space.  (Compare 
Manual  Pelvimetry.) 

4.  The  Diagonal  Conjugate  (Fig.  209). — This  is  the  distance  from  the  center 
of  the  sacral  promontory  to  the  subpubic  ligament.  To  measure  it  manually, 
the  first  and  second  fingers  of  either  hand  are  introduced  into  the  vagina,  and 
the  sacral  promontory  is  sought  for.  Some  experience  is  necessary  to  be  able 
to  recognize  the  promontory,  and  care  should  be  taken  not  to  mistake  a  "  false 
promontory"  for  the  true  one.  Unless  the  deformity  is  extreme  it  will  be 
the  second  finger  which  touches  the  promontory.  Keeping  the  finger  in  contact 
with  the  latter,  the  radial  side  of  the  first  finger  or  hand  is  held  firmly  against 
the  subpubic  ligament,  while  the  exact  point  of  contact  is  marked  by  the  finger- 
nail of  the  first  finger  of  the  other  hand  (Fig.  209).  The  fingers  are  then  with- 
drawn, and  the  distance  is  measured  with  the  pelvimeter  (Fig.  211)  or  tape, 
the  examining  hand  being  held  in  the  same  relative  position.  This  diameter  in 
normal  pelves  measures  5^  inches  (13.5  cm.). 

5.  The  True  Conjugate. — The   true    conjugate  can  be  estimated  from  the 


THE  EXAMINATION  OF  PREGNANCY. 


169 


r*h 


Fig.   208. — Digital  Method  of  Measuring  the  Antero-posterior  Diameter    of  the 
Pelvic  Outlet. —  (From  a  photograph.) 


\ 


.^ittJauiiitaiimMtti.- 


FiG.   209. — Digital  Method  of  Measuring  the  Diagonal  Conjugate  of  the  Pelvic 

Inlet. — (From  a  photograph.) 


170 


PHYSIOLOGICAL  PREGNANCY. 


diagonal  conjugate,  by  constructing  a  triangle  formed  by  the  two  conjugates 
and  the  symphysis  pubis,  of  which  the  diagonal  conjugate  corresponds 
nearly  to  the  hypothenuse,  and  the  true  conjugate  to  the  base.  The  diagonal 
conjugate,  the  known  quantity,  is  the  longest  of  the  three  sides,  and  the  true 
conjugate,  the  unknown  quantity,  can  be  obtained  from  it  by  subtracting  on 
an  average  i  inch  (2.5  cm.).  The  amount  to  be  deducted,  however,  will  vary 
with  the  height,  thickness,  and  inclination  of  the  symphysis  and  the  height  of 
the  sacral  promontory.  When  the  symphysis  is  i-|  inches  (3.75  cm.)  or  over, 
f  inch  (1.905  cm.)  should  be  subtracted  from  the  diagonal  conjugate;  and  when 
it  is  less  than  1^  inches  (3.75  cm.),  a  little  less  is  to  be  subtracted.     The  esti- 


FiG.  210, — Method  of  Measuring  the  Transverse  Diameter  of  the  Pelvic  Outlet. 
The  points  of  the  pelvimeter  are  placed  on  the  palmar  surfaces  of  the  tips  of  the  index- 
fingers.     See  diagram,  upper  left  of  illustration. — {From  a  photograph.) 


mation  of  the  true  conjugate  by  this  plan  can  only  be  approximated,  since  it 
depends  upon  so  many  variable  quantities.  The  method  of  taking  the  height 
of  the  symphysis  is  described  on  page  166.  For  determining  the  thickness  of 
the  symphysis  the  pelvimeter  of  Skutsch,  or  one  of  its  modifications,  may  be 
used  (Fig.  215).  It  can  be  roughly  estimated,  of  course,  by  the  thumb  and 
finger  of  the  accoucheur  (Fig.  213).  The  normal  angle  between  the  true  conju- 
gate and  the  symphysis  has  been  estimated  at  105  degrees.  After  the  physi- 
cian has  made  it  a  rule  to  combine  internal  pelvimetry  with  vaginal  examina- 
tion, he  will  soon  learn  to  recognize  and  appreciate  departures  from  the  normal 
type.     An  important  point,  commonly  misunderstood,  is  that  the  obstetric  con- 


THE  EXAMINATION   OF  PREGNANCY. 


171 


jugate  is  the  smallest  amount  of  available  intrapelvic  space  in  the  antero- 
posterior diameter,  whether  measured  from  the  true  promontory  or  some  other 
point,  as  a  false  promontory  or' displaced  lumbar  vertebra. 

True  Conjugate  with  Pelvimeters  (Skutsch). — Many  pelvimeters  have  been 
devised  for  measuring  the  true  conjugate. 
These  instruments,  as  a  rule,  do  not  take 
cognizance  of  other  internal  diameters. 
Two  instrumental  methods  for  measuring 
the  true  conjugate  give  practical  results: 
viz.,  those  of  Skutsch  and  Farabeuf  re- 
spectively. The  measurement  which  the 
former  gives  is  known  as  the  interno- 
external,  and  is  not  so  accurate  as  that 
obtained  by  the  direct  method  with  the 
latter  or  Farabeuf's  instrument.  (See 
page  172  and  Fig.  214.)  Eight  years'  ex- 
perience with  this  instrument  has  satis- 
fied the  author  that  it  is  the  most  accur- 
ate instrument  for  the  purpose  at  present 
in  existence. 

The  Skutsch  pelvimeter  is  about  the 
shape  of  a  pair  of  calipers  (Fig.  215).  Its 
internal  arm  is  of  steel,  with  a  spatula- 
like tip,  while  its  fellow  is  of  pure  lead 
covered  with  india-rubber  tubing.  To  de- 
termine the  true  conjugate,  the  woman  is 
placed  in  the  dorsal  position,  with  knees 
elevated  and  thighs  separated.  The  sac- 
ral promontory  is  first  located,  and  then 
the  projecting  point  on  the  internal  aspect 

of  the  symphysis.  A  point  is  then  selected  upon  the  mons  veneris  correspond- 
ing to  an  imaginary  continuation  of  the  true  conjugate,  and  indicated  by  a 
crayon  mark.  The  internal  or  steel  arm  is  then  introduced  into  the  vagina, 
with  the  finger  as  a  guide,  and  its  spatula-like  tip  applied  firmly  to  the  pro- 
montory and  there  maintained, 
while  with  the  other  hand  the 
lead  arm  is  given  such  a  contour 
that  its  terminal  knob  is  placed 
near  the  marked  spot  upon  the 
mons.  The  external  hand  then 
gives  the  pelvimeter  a  slight 
twist  upon  its  axis,  after  which 
the  knob  of  the  external  arm 
may  be  pressed  accurately  upon 
the  marked  spot.  The  pelvim- 
eter is  then  locked  and  with- 
drawn. The  distance  is  meas- 
ured by  the  scale  accompanying 
the  instrument.  The  internal  arm  of  the  pelvimeter  is  then  applied  to  the 
internal  aspect  of  the  symphysis,  and  its  distance  from  the  marked  point  upon 
the  mons  veneris  is  determined,  in  the  same  manner  as  was  the  first  measure- 
ment.    Subtraction  of  the  small  from  the  large  measurement  gives  the  length 


Fig,  211. — Measuring  the  Distance 
FROM  THE  End  of  the  Second  Fin- 
ger TO  the  Mark  Made  upon  the 
Radial  Bqrder  of  the  Hand. 


Fig.    212. — Stein's    Pelvimeter    for    Measuring 
Directly  the  True  Conjugate. 


172 


PHYSIOLOGICAL  PREGNANCY. 


\ 


of  the  true  conjugate.     The  Skutsch  pelvimeter  is  in  Hke  manner  used  to  measure 
the  transverse  diameter  of  the  pelvic  inlet.      (See  Fig.  216.) 

True  Conjugate  with  the  Farabeuf  Pelvimeter. — This  resource  was  intro- 
duced into  pelvimetry  by  Farabeuf  *  for  the  purpose  of  lengthening  the  index- 
finger,  in  case  the  accoucheur  should  be  unable  to  reach  the  promontory,  either 
by  reason  of  the  shortness  of  his  finger,  or  because  of  unusual  dimensions  of 
the  pelvis.  While  fingers  of  average  length  are  sufficient  for  pelvimetry  in 
contracted  pelves,  this  is  by  no  means  necessarily  the  case  in  general  pelvim- 
etry, and  therefore  the  device  of  Farabeuf  is  excellent  in  routine  obstetrical 
practice.  The  custom  of  reinforcing  the  finger  with  a  vesical  sound  is  open 
to  criticism,  from  the  fact  that  it  may  be  given  a  wrong  direction;  and  a  further 
disadvantage  is  the  absence  of  a  device  to  indicate  the  exact  position  of  the 

symphysis.  The  thimble-like 
pelvimeter  consists  of  two  deli- 
cate steel  arms,  which  are  par- 
li-'-^sc^^-  ^  allel  for   a  short   distance,  but 

which  then  diverge,  and  after- 
ward roughly  assume  the  con- 
tour of  a  tapering  forefinger. 
This  frame  is  provided,  on  its 
inferior  surface,  with  two  in- 
complete rings,  designed  to  fit 
the  first  and  second  phalanges 
of  the  exploring  finger.  The 
elasticity  of  the  steel  arms  per- 
mits the  rings  to  slip  over  a  finger 
of  any  normal  dimensions.  At- 
tached near  the  extremity  of  this 
steel  frame  is  a  delicate  horse- 
shoe-shaped piece  of  steel,  which 
turns  in  either  direction,  up  or 
down,  and  which  constitutes  the 
extension  to  the  exploring  finger 
(Fig.  214).  The  parallel  portion 
of  the  steel  arms  also  constitutes 
a  groove,  along  which  slides  the 
measuring  rod,  which  is  bent  at 
its  terminal  end  into  a  right 
angle.  This  bent  portion  is  in- 
tended to  enter  the  urethra  in  order  to  touch  the  internal  aspect  of  the  sym- 
physis. The  proximal  end  is  provided  with  a  ring,  while  the  upper  surface  of 
the  rod  has  a  graduated  index  (Fig.  214).  With  this  pelvimeter  the  obstetrical 
conjugate  can  be  measured  directly.  The  steel  arms  are  introduced  against 
the  promontory,  followed  by  the  passing  of  the  measuring  rod  into  the  bladder 
(Fig.  214). 

6.  Transverse  Diameter  of  the  Inlet  (Fig.  216). — Exact  measurements  of  the 
transverse  diameter  of  the  brim  are  as  yet  hardly  practicable.  The  pelvimeter  of 
Skutsch  is  an  example  of  what  has  been  done  in  this  direction  (Fig.  216). 
To  obtain  the  transverse  diameter  at  the  pelvic  inlet  with  this  instrument,  the 
woman  is  placed  in  the  dorsal  position  with  her  extremities  in  leg-holders. 
The  fingers  of  the  left  hand  are  introduced  within  the  vagina  and  along  the 
*  "  Gaz.  Hebdom.  de  Med.  et  Chir.,"  June,  1889 


Fig.  213. — Measuring  the  Height  and  Thick- 
ness OF  THE  Symphysis  with  the  Fingers. 
This  procedure  is  also  useful  to  determine  the 
amount  of  engagement  of  the  presenting  part 
or  the  effect  of  the  uterine  contractions  in  causing 
descent  of  the  head  or  breech. 


THE   EXAMINATION  OF  PREGNANCY. 


173 


Fig.    214. — Direct   Instrumental   Method   of   Measuring   the   True   Conjugate   op 
THE  Pelvic  Inlet  with  the  Farabeuf  Pelvimeter. — {From  a  photograph.) 


Fig.  215.— Measuring  the  True  Conju- 
gate OP  THE  Pelvic  Inlet  with  the 
Skutsch  Pelvimeter. 


Fig.  2^6. — Measuring  the  Tra.ms- 
verse  Diameter  of  the  Pelvic 
Inlet  with  the  Skutsch  Pelvim- 
eter. 


174 


PHYSIOLOGICAL   PREGNANCY. 


Fig.  217. — Direct  Internal  Manual  Pelvimetry  in  a  Normal  Pelvis.  The  width 
of  the  hand  is  3^  inches  (9  cm.).  Note  the  free  space  between  the  promontory  and 
small  finger. — (From  a  photograph.) 


Fig.  218. — Direct  Internal  Manual  Pelvimetry  in  a  Normal  Pelvis.  The  long 
diameter  of  the  closed  fist  is  4  inches  (10  cm.).  Note  the  tmoccupied  room  to  the 
front  and  sides  of  the  fist. — (From  a  photograph.) 


THE  EXAMINATION  OF   PREGNANCY. 


175 


linea  arcuata,  while  the  right  hand  locates  the  point  at  which  an  imaginary- 
continuation  of  the  transverse  diameter  would  transfix  the  skin  in  the  region 
of  the  hip.  This  point  is  indicated  by  a  crayon  mark.  The  error  in  the  deter- 
mination of  this  point  is  said  to  be  very  slight.  The  internal  arm  of  the  pel- 
vimeter is  now  introduced  within  the  vagina,  and  its  tip  is  applied  to  the  left 
extremity  of  the  transverse  diameter,  while  the  knob  of  the  lead  arm  is  similarly 
applied  o•^er  the  hip  and  the  short  measurement  taken.  The  steel  arm  within 
the  vagina  is  now  reversed,  so  that  its  convexity  faces  about;  the  opposite 
extremity  of  the  transverse  diameter  is  then  located,  and  the  long  measure- 
ment made.  The  difference  between  the  two  gives  the  diameter  sought.  An 
internal    measurement    sometimes    taken    in   order  to  estimate  the  transverse 


Fig.  219. — Direct  Internal  Manual  Pelvimetry  in  a  Normal  Pelvis.  The  long 
diameter  of  the  fist  as  thus  placed  in  the  pelvis  measures  4  inches  (10  cm.).  Note 
the  space  between  the  promontory  and  the  knuckle  of  the  small  finger. — (From  a  photo- 
graph.) 


diameter  of  the  pelvic  brim  is  that  of  Lohlein.  With  two  fingers  in  the  vagina, 
the  distance  from  the  center  of  the  ligamentum  arcuatum  to  the  upper  anterior 
angle  of  the  great  sacro-sciatic  notch  is  taken.  According  to  Lohlein,  this  is 
f  inch  (2  cm.)  less  than  the  transverse  diameter  of  the  inlet.  The  practised 
hand  will  soon  learn  to  appreciate  any  notable  transverse  contraction  in  pal- 
pating the  lateral  pelvic  walls. 

Internal  Manual  Pelvimetry. — Internal  manual  pelvimetry  comprises  pal- 
pation of  the  pelvic  canal  by  the  fingers  introduced  within  the  vagina,  and 
measurement  of  the  pelvic  diameters  by  the  aid  of  the  entire  hand.  Palpation 
of  the  pelvic  canal  serves  to  detect  the  presence  of  objects  which  obstruct  the 
lumen  of  the  pelvic  canal,  such  as  abnormally  long  bony  prominences.  But 
unless  favored  by  circumstances  which  render  possible  the  introduction  of  the 


176 


PHYSIOLOGICAL   PREGNANCY. 


entire  hand  into  the  vagina,  such  as  large  size  and  great  distensibility  of  the 
latter,  the  value  of  mere  palpation  of  the  pelvic  canal  is  not  great. 

For  a  number  of  years  the  author  has  practised  a  variety  of  manual  pel- 
vimetry shown  in  figures  217  to  221.  The  originator  of  this  method  was  Dr. 
Robert  Wallace  Johnson,  of  England.  It  necessitates  the  introduction  of  the 
whole  hand  into  the  pelvis,  a  distensible  vagina,  and  narcosis  of  the  patient. 
It  is  inapplicable  in  nulliparous  patients,  and  in  many  primigravidas  before 
labor  sets  in,  but  can  be  used  to  advantage  in  most  multigravidae,  and  in  all 
parturients.  In  all  primiparse  and  many  multiparae  considerable  care  and 
time  must  be  used  in  the  dilatation  of  the  vagina,  so  as  to  avoid  rupture  of 
that  organ  or  of  varicose  veins  so  often  present.     Troublesome  venous  hemor- 


FiG.  220. — Direct  Internal  Manual  Pelvimetry  in  a  Generally  Contracted  Pelvis. 
Note  that  the  long  diameter  of  the  fist  reaches  from  promontory  to  symphysis.  Also 
that  the  circumference  of  the  fist  almost  blocks  the  pelvic  inlet. — {From  a  photograph.) 


rhage  from  the  latter  source  once  occurred  in  my  practice  from  a  too  rapid 
dilatation.  As  the  illustrations  indicate,  the  measurements  of  the  pelvic  inlet 
are  compared  with  the  known  circumference  and  diameters  of  the  tightly 
closed  fist.  When  applicable,  the  method  is  the  most  positive  and  satisfactory 
of  the  internal  means  for  determining  the  available  space  at  the  inlet. 

It  should  not  be  forgotten  that  pelvic  contraction  is  usually  relative,  not 
absolute,  and  that  the  size  of  the  fetal  head  is  just  as  important  as  the  size 
of  the  pelvis.  The  size  and  compressibility  of  the  head,  and  whether  it  can 
be  made  to  enter  the  pelvic  brim,  are  factors  that  should  never  be  neglected. 
(See  Cephalometry.)  Finally,  the  importance  in  doubtful  cases  of  a  thorough 
examination  under  full  anesthesia,  and  by  an  experienced  accoucheur,  cannot 
be  overestimated.     It  is  hardly  necessary  to  point  out  all  the  refinements  of 


THE  EXAMINATION   OF  PREGNANCY. 


177 


diagnosis  in  the  various  forms  of  pelvic  deformity.  The  educated  hand  will 
recognize  the  difference  in  the  respective  lateral  pelvic  walls,  which  accom- 
panies the  obliquely  contracted  pelvis  (Naegele);  the  converging  walls  and 
approximated  ischial  tuberosities,  which  characterize  the  funnel-shaped  pelvis 
(Roberts) ;  the  presence  of  bony  tumors,  etc.  The  student  who  has  mastered  the 
principles  of  pelvimetry,  and  the  descriptive  classification  of  pelvic  deformity, 
will  not  need  exact  instruction  for  every  possible  case. 

RONTGEN   PELVIMETRY. 

The  :r-rays  are  able  to  detect  anomalies  of  the  bony  pelvis,  including  narrow- 
ing of  the  inlet.  We  therefore  possess  a  new  resource  in  pelvimetry.  Accord- 
ing to  Bouchacourt,  the  rays  give  us  three  species  of  information:  (i)  As  to 


Fig.  22  1. — Internal  Direct  Manual  Pelvimetry  in  a  Flattened  and  Generally 
Contracted  Pelvis.  Note  that  the  fist  almost  fills  the  pelvic  inlet. — {From  a  photo- 
graph.) 


the  presence  or  absence  of  deformity  in  general.  (2)  As  to  whether  the  deformity 
is  symmetrical  or  asymmetrical.  (3)  As  to  the  nature  of  the  deformity.* 
To  practise  Rontgen  pelvimetry,  the  woman  is  placed  upon  the  plate  in  a  some- 
*  "L'0bst6trique,"  1900,  v,  pp.  20-34. 


12 


178  PHYSIOLOGICAL  PREGNANCY. 

what  reclining  position,  the  tube  being  above  and  in  front  of  her;  or  she  may- 
lie  in  the  lithotomy  position,  with  the  plate  under  the  ischial  tuberosities,  if 
possible  at  a  right  angle  with  the  pelvic  axis,  the  tube  being  above  the  woman 
in  a  line  with  the  said  axis.  Freund  speaks  of  a  third  position — namely,  the 
Trendelenburg — as  specially  adapted  for  pelvic  photography.  Finally,  if  a 
picture  of  the  rear  of  the  pelvis  is  desirable,  the  patient  must  lie  prone  with 
the  plate  beneath  and  the  tube  above  her.  Williams  *  gives  a  method  of  his 
own  devising,  for  measuring  the  transverse  diameter  of  the  pelvis  at  the  inlet. 

PELVIGRAPHY. 

Attempts  have  been  made  to  depict  the  entire  pelvic  cavity  during  life 
by  some  method  of  graphic  representation.  As  far  as  I  know,  but  two  such 
methods  have  ever  been  proposed;  these  are  skiagraphy  of  the  pelvis,  and  the 
geometrical  method  of  Neumann  and  Ehrenfest,  assistants  of  Professor  Schauta 
(Vienna).  Skiagraphy  of  the  pelvis  is  described  under  the  sections  on  Rontgen 
Pelvimetry  (page  177)  and  Rontgen  Cephalometry  (page  184). 

The  geometrical  method  consists  in  taking  a  series  of  measurements  of  certain 
pelvic  diameters,  and  plotting  the  size  and  outline  of  various  pelvic  planes. 
The  two  transverse  diameters  and  the  sagittal  plane  are  sufficient  to  give  a  com- 
plete notion  as  to  the  individuality  of  the  pelvis.  The  authors  just  mentioned 
employ  for  this  purpose  an  instrument  termed  by  them  a  pelvigraph.  The 
principle  involved  in  the  construction  and  application  of  the  pelvigraph  is 
that  of  the  parallel  rulers,  one  number  representing  a  palpator  for  the  localiza- 
tion of  points  within  the  pelvis,  while  the  other  is  provided  with  a  water-level 
and  a  dial  index.  There  are  several  palpating  arms,  the  peripheral  portions 
of  which  are  bent  in  various  curves  or  angles,  to  reach  different  parts  of  the 
pelvis;  but  the  proximal  portion  and  the  terminal  button  are  always  in  the 
same  axis.  The  various  measurements,  angles,  etc.,  are  plotted  upon  drawing- 
paper  as  soon  as  they  are  determined,  and  in  this  manner  the  entire  sagittal 
plane  is  reproduced  on  paper.  The  transverse  diameters  should  then  be 
measured.  This  method  may  be  found  fully  described  and  illustrated  in  the 
"  Monatsschrift  fur  Geburtshiilfe  und  Gynakologie,"   1900. 

Fabre's  Method. — In  1900,  Fabre,  of  Lyons,  described  before  the  Interna- 
tional Medical  Congress  at  Paris  a  method  devised  by  him  for  measuring  the 
superior  strait,  which  he  termed  metric  radiography.  Exact  mensuration 
with  radiography  is  of  course  impossible,  as  the  image  varies  with  the  distance 
between  the  ampulla  and  the  various  positions  of  the  pelvis.  But  it  is  possible 
to  measure  the  dimensions  approximately  by  the  method  about  to  be  described. 
Four  rulers  of  metal,  each  provided  with  a  certain  number  of  saw-like  teeth, 
form  a  square  about  the  pelvis.  The  posterior  ruler  is  opposite  the  posterior 
superior  ischial  spines,  the  anterior  lies  horizontally  in  front  of  the  upper  por- 
tion of  the  pubis,  etc.  A  skiagram  is  then  made,  and  the  shadows  of  the  teeth, 
which  should  be  exactly  opposite  to  one  another,  may  be  joined  by  straight 
lines,  dividing  the  area  of  the  pelvic  shadow  into  minute  squares,  whereby  the 
dimensions  desired  may  be  measured  approximately. 

CLISEOMETRY. 

Cliseometry  is  the  art  of  measuring  the  size  of  the  angle  of  inclination  of  the 
planes  of  the  pelvic  inlet  and  outlet.     For  many  years  obstetricians  have  sought  a 
practical  and  trustworthy  method  for  determining  these  angles.    Some  authorities 
*  '  The  Rontgen  Rays  in  Medicine  and  Surgery,"  1901,  p.  378. 


THE  EXAMINATION   OF  PREGNANCY. 


179 


have  seen  in  cliseometry  a  valuable  prospective  resource  in  the  differential  diag- 
nosis of  pelvic  deformities,  while  others  believe  that  the  subject  of  forceps-traction 
should  benefit  most  from  increased  study  of  the  inclination.  Cliseometers  have 
been  devised  by  Naegele,  Rit-gen,  Prochownik,  and  others,  but  no  one  apparatus 
has  ever  attained  any  considerable  degree  of  recognition.  Sources  of  error,  cum- 
brousness,  and  general  impracticability  have  thus  far  attended  all  attempts  to 
systematize  and  popularize  cliseometry.  Neumann  and  Ehrenfest  *  have  intro- 
duced a  device  for  measuring  the  pelvic  inclination,  which  they  term  a  cliseometer 
(Fig.  222).  It  consists  of  a  rigid  curve  (A),  which  carries  at  one  end  a  hollow 
cylinder  rod  (B),  so  disposed  that  it  lies  directly  in  the  axis  of  the  free  extremity  of 
the  curve,  which  is  armed  with  a  knob  (C);  the  hollow  cylinder  contains  a  solid 


Fig.  222. — Method  of  Measuring  the  Degree  of  Pelvic  Inclination. 
(Instrument  of  Neumann  and  Ehrenfest.) 


Cliseometry. 


rod  (D),  which  sUdes  up  and  down,  and  is  armed  with  a  second  knob  (F).  The 
two  knobs  are  naturally  in  the  same  axis.  The  upper  extremity  of  the  moving 
rod  contains  a  disc  (G),  which  rotates  in  the  direction  of  the  length  of  the  rod. 
The  periphery  of  the  disc  is  divided  into  degrees.  Above  and  below  are  zero 
marks,  and  the  numbering  is  so  arranged  that  there  are  four  quadrants^  of  90 
degrees  each.  The  disc  is  also  provided  with  a  water-level  and  an  index.  When 
the  cliseometer  is  so  placed  that  the  axis  in  which  the  knobs  lie  is  horizontal, 
the  index  points  to  o.  If  the  knobs  are  apphed  to  the  points  used  in  measuring 
the  external  conjugate  with  a  pelvimeter,  and  the  disc  is  then  rotated  until 
the  water-level  is  horizontal,  the  zero  points  are  also  horizontal.     The  angle 

*  "  Monatsschrift  f.  Geburts.  und  Gynakol.,"  1900,  vol.  xi. 


180 


PHYSIOLOGICAL   PREGNANCY. 


made  by  the  cylindrical  rod  and  knobs  with  the  horizontal  plane,  or  diameters 
between  the  zero  marks,  represents  the  inclination  of  the  plane  of  the  inlet.* 

CEPHALOMETRY. 

Various  procedures  have  been  devised  for  the  determination  of  the  diameters 
of  the  fetal  skull,  especially  the  biparietal  and  the  bitemporal.  Attempts 
have  been  made  to  measure  the  skull  directly — that  is,  through  the  intervening 
soft  parts ;  to  estimate  the  size  of  the  skull  through  measurements  of  more 
accessible  fetal  structures;  and,  finally,  to  estimate  the  cranial  dimensions  by 
the  duration  of  pregnancy. 

I.  From  the  Period  of  Gestation. — Dubois's  Method. — From  numerous  meas- 


rz^ 


Fig.  223. — Ferret's  Method  of  Cephalometry  and  Instrument. 


urements  of  the  fetal  skulls  after  premature  deliveries,  controlled  by  the  supposed 
duration  of  pregnancy,  Dubois  arrived  at  the  following  relationship  between 
the  month  of  gestation  and  the  biparietal  diameter:  seven  months,  2^  inches 
(7  cm.);  eight  months,  33-  inches  (8  cm.);  eight  and  a  half  months,  T^i^  inches 
(8.5  cm.);  term,  4  inches  (9  cm.).  Unfortunately  for  this  relationship,  we 
cannot  usually  determine  the  duration  of  pregnancy,  and  therefore  but  little 
practical  benefit  is  derived  from  the  application  of  such  a  method  to  fetometry. 
2.  Direct  Abdominal  Cephalometry. — Ferret's  Method  (Fig.  223). — Perret  was 
the  first  to  practise  the  measurement  of  the  fetal  head  through  the  abdominal 
wall.  The  foundation  of  this  method  was  laid  in  the  results  of  craniometry  of  the 
newly  bom.  Numerous  measurements  had  shown  Perret  that  whatever  the  length 
of  the  biparietal  diameter,  the  occipito-frontal  measurement  is  approximately  i 

*  The  instrument  of  Neumann  and  Ehrenfest  is  made  by  M.  Schurr,  Vienna,  IV  Schaum- 
btirgerstrasse,  No.  7a.      I  obtained  my  instrument  through  the  Kny-Scheerer  Co.,  New  York. 


THE  EXAMINATION   OF  PREGNANCY. 


181 


inch  (2.54  cm.)  longer;  so  that  if  it  were  possible  to  measure  the  occipito-frontal 
diameter  in  utero,  the  shorter  measurement  could  be  calculated  with  ease. 
For  the  practice  of  external-  cephalometry,  or  the  measurement  of  the  occipito- 
frontal diameter  of  the  fet-us  through  the  abdominal  wall,  the  cephalometer 
devised  by  Perret  is  employed.  This  apparatus  is  simply  a  spherical  compass, 
such  as  is  sometimes  used  in  external  pelvimetry,  but  the  knobs  which  arm  the 
branches  of  a  pelvimeter  are  replaced  by  a  special  device  for  overcoming  the 
difficulties  which  are  incident  to  mensuration  through  the  thick  abdominal  wall 
(Fig.  223).  Ferret's  description  of  this  device  is  as  follows*:  "At  the  extremity 
of  each  branch  is  a  flattened  blade,  so  shaped  as  to  be  held  readily  between  the 
fingers.  These  httle  blades  revolve  on  their  axes  in  slots  which  exist  in  the  tips 
of  the  branches  of  the  compass.  On  account  of  this  mobility,  the  fingers  of  the 
operator  enjoy  a  corresponding  freedom  of  movement.  With  the  fingers  in  posi- 
tion, that  end  of  the  blade  which  corresponds  to  the  palmar  surface  and  projects 
beyond  is  furnished  with  a  convex  button." 

Ferret's  method  of  using  his  cephalometer  is  as  follows:  The  woman  is  placed 
on  her  back,  and  the  operator  ap- 
plies his  hands  to  each  side  of  the 
abdomen,  just  as  when  seeking  to 
determine  whether  or  not  the  head 
is  engaged  (Fig.  223).  If  engage- 
ment has  occurred,  the  procedure 
must  be  abandoned.  Otherwise  the 
operator  begins  to  palpate  with  the 
short  movable  blades  (which  fur- 
nish the  tips  of  the  branches  of  the 
cephalometer)  the  head  between 
the  terminal  phalanges  of  the  mid- 
dle and  ring  fingers  of  both  hands. 
As  the  palpating  finger-tips  locate 
the  head,  an  attempt  is  made  to 
press  the  cephalometer  buttons 
against  the  forehead  and  occiput  of 
the  child.  When  this  has  been  ac- 
complished, the  distance  is  read 
off  on  the  scale  of  the  apparatus. 

The  thickness  of  the  abdominal  wall  is  next  measured  directly,  by  pinching 
up  a  fold  of  the  latter,  and  is  deducted  from  the  fetal  measurement  (Fig. 
224).  The  result  should  be  the  occipito-frontal  diameter  of  the  child's 
head.  If  now  we  subtract  i  inch  (2.54  cm.),  we  obtain  the  biparietal 
diameter.  The  cephalometer  has  been  in  constant  use  in  the  Tamier  clinic  in 
Paris  for  a  number  of  years.  In  the  hands  of  Ferret  and  others  the  results  are 
surprisingly  good,  the  error  between  the  intrauterine  and  extrauterine  measure- 
ments being  insignificant  in  the  majority  of  cases;  so  that  in  the  hands  of  one 
specially  trained,  cephalometry  may  be  termed  a  practical  success.  On  the  con- 
trary, others  have  published  series  of  cases  in  which  the  error  was  so  great  as  to 
invalidate  the  results  of  the  method  for  ordinary  practice.  What  has  thus  far 
been  said  of  Ferret's  cephalometry  refers  only  to  labor  at  term,  the  mensuration 
having  for  its  immediate  object  the  determination  of  disparities  between  the 
measurement  of  the  head  and  pelvis.  There  is,  however,  a  second  and  equally 
important  indication  for  cephalometry  in  connection  with  artificial  premature 

*  "L'Obst^trique,"  Nov.,  1899. 


Fig.  224. — Measuring  the  Thickness  of  the 
Anterior  Abdominal  Wall. 


182 


PHYSIOLOGICAL  PREGNANCY. 


delivery.  Given  the  dimensions  of  a  contracted  pelvis,  ceplialometry  should 
determine  the  maximum  size  of  the  head  compatible  with  natural  delivery,  and 
indicate  the  period  at  which  pregnancy  should  be  terminated. 

The  ratio  between  the  two  cranial  diameters  of  the  fetus  holds  good  for 
the  seventh,  eighth,  and  ninth  months,  the  difference,  i  inch  (2.54  cm.),  being 
in  reality  the  average  difference  of  all  skulls  having  a  biparietal  diameter  of 
from  3  to  3^  inches  (7.62  to  8.89  cm.).  Labor  must  be  interrupted,  of  course, 
before  the  biparietal  diameter  becomes  longer  than  the  true  conjugate.  The 
results  of  Perret  and  others,  in  this  department  of  obstetrics,  appear  to  show 
that  his  method  is  of  undoubted  value  in  aiding  in  the  choice  of  that  moment 
for  the  interruption  of  pregnancy  which  shall  be  most  advantageous  for  the 
interests  of  mother  and  child  alike. 

3.  Stone's  Method  of  Cephalometry  (Fig.  225). — This  is  a  modification  of 


Fig.  225. — Stone's  Method  of  Cephalo- 
metry. 


Fig.  226. — Determining  the  Capability  of 
THE  Head  to  Descend  into  the  Pelvis. 
Muller's  Method  of  Cephalometry. — 
{Bumnt.) 


Ferret's  method.  An  ordinary  pelvimeter  is  used,  and  no  deduction  is  made  for 
the  thickness  of  the  abdominal  and  uterine  walls.  The  patient  is  in  the  ordinary 
dorsal  posture,  and  the  examiner  standing  on  one  side,  facing  the  patient's  feet, 
carefully  palpates  and  makes  out  the  position  of  the  fetal  head.  If  it  is  already 
engaged  in  the  pelvis,  it  will  not  only  be  impracticable,  but  also  unnecessary  to 
measure  it.  The  occipital  and  frontal  poles  are  now  grasped  between  the  two 
hands,  and  an  assistant  places  from  below  the  ends  of  the  pelvimeter  between 
the  terminal  phalanges  of  the  middle  and  ring  fingers  of  the  examiner,  pushing 
them  firmly  inward  as  the  examiner  directs.  An  assistant  or  nurse  is  necessary 
to  obtain  the  best  results,  in  order  that  the  examiner's  fingers  may  be  entirely 
free  accurately  to  locate  the  fetal  head  (Fig.  225).  From  this  measurement 
obtained,  namely,  the  occipito-frontal  diameter,  is  subtracted  one  inch  (2.5  cm.), 
which  is  the  average  difference  at  the  seventh,  eighth,  and  ninth  months  between 
the  occipito-frontal  and  biparietal  diameters.     Stone  found  the  average  difference 


THE  EXAMINATION   OF  PREGNANCY. 


183 


to  be  2.33  cm.  in  one  hundred  measurements,  and  he  subtracts  2  cm.  for  heads 
with  an  occipito-frontal  diameter  of  less  than  4.2  inches  (11  cm.)  and  one  inch 
(2.5  cm.)  for  those  above  this  .measurement.  Thus  fairly  accurate  results  will 
be  obtained  and  sufficient  amount  will  be  allowed  for  the  moulding.* 

4.  Manual  Engagement  of  the  Head. — Miiller's  Method  (Fig.  226). — The 
relations  which  exist  between  the  head  and  pelvis  may  often  be  determined 
by  various  manual  procedures.  The  so-called  method  of  Miiller  has  been 
brought  into  regular  and  systematic  use  by  prominent  obstetricians  of  Paris, 


•■-mHI^ 


Fig.  227. 


-Determining  any  Disproportion  between  the  Fetal  Head  and  the  Pelvic 
'  Inlet. 


under  the  name  of  '' palper-mensurateur ,"  given  it  by  Pinard.  According  to 
Budin,  it  is  sufficient  to  make  an  attempt  to  engage  the  head  in  the  pelvis,  by 
pressure  exerted  through  the  abdominal  wall,  as  in  Hofmeier's  method  for 
securing  the  engagement  of  the  head  during  labor.  (See  Labor.)  After  the 
bladder  and  rectum  have  been  emptied,  the  accoucheur  places  a  hand  on 
each  side  of  the  hypogastrium  (Fig.  227),  the  head  being  in  relation  with  the 
inlet.  Pressure  is  then  made  in  the  axis  of  the  superior  strait,  so  that  the  head 
is   forced  into  the  pelvic  cavity.     If  this  engagement  can  be  brought  about, 

*W.  S.  Stone,   "Antepartum    Measurement    of   the    Fetal    Head,"   "  N.  Y.  Medical 
Record,"  November  4,  1905,  p.  725. 


184  PHYSIOLOGICAL  PREGNANCY. 

it  is  evident  that  labor  should  be  normal.  The  head  enters  the  pelvis  more 
readily  if  the  patient  is  so  placed  that  the  long  axis  of  the  uterus  is  vertical  and 
at  right  angles  to  the  plane  of  the  inlet.  The  manceuver  is  disagreeable  to 
many  women,  and  is  also  difficult  of  execution  if  the  abdominal  walls  are  thick 
and  resistant,  but  it  renders  real  service,  giving  valuable  information  to  the 
physician.  I  have  found  it  more  reliable  to  introduce  the  whole  hand  into  the 
vagina,  and  with  the  fingers  spread  over  the  head  to  have  an  assistant  exert 
pressure  on  the  hypogastrium  to  secure  engagement  of  the  head  (Fig.  227). 
The  internal  hand  then  estimates  the  relation  between  the  size  of  the  head 
and  the  inlet.  Perret,  in  comparing  his  method  of  cephalometry  with  the 
"palper-jnejisurateur,"  states  that  it  cannot  be  applied  in  nervous  women,  in 
cases  of  vicious  insertion  of  the  placenta,  hydramnios,  thick  abdominal  walls, 
or  in  any  case  after  labor  has  begun.  It  is,  of  course,  applicable  in  head 
presentations  only.  The  "palper-mensuratetir"  also  gives  false  information  at 
times.  Thus,  it  appears  to  indicate  that  delivery  is  impossible  in  cases  in  which 
the  pelvis  is  normal,  and  failure  to  engage  is  due  to  trouble  higher  up  (false 
lumbar  promontory,  tumors,  etc.). 

5.  Internal  Manual  Cephalometry. — A  fairly  accurate  estimate  of  the  size 
of  the  fetal  head  may  be  obtained  by  introducing  the  whole  hand  into  the  vagina 
after  full  dilatation  of  the  cervix,  and  grasping  the  head  with  the  extended  fingers, 
then  with  firm  suprapubic  pressure  with  the  other  hand  attempting  to  engage 
head  and  fingers  together  (Fig.  227);  or  one  can  simply  grasp  the  head  as  in 
Fig.  226,  and  estimate  its  size  by  palpation. 

6.  Rontgen  Cephalometry. — As  will  be  seen  by  referring  to  the  section  on 
Rontgen  pelvimetry,  recognition  of  pelvic  anomalies  is  relatively  simple.  The 
great  problem  to  overcome  is  the  photography  of  the  fetus.  If  a  combined 
shadow  of  both  the  head  and  pelvis  could  be  obtained,  much  light  would  be 
thrown  upon  the  relations  existing  between  these  structures  in  individual 
cases.  In  1898,  Gocht  *  announced  that  photography  of  the  fetal  skeleton 
was  impracticable.  Varnier,  however,t  succeeded,  after  more  than  three  years 
of  effort,  in  obtaining  a  clear  view  of  the  contour  of  the  fetal  head  in  a  woman 
seven  months  pregnant,  so  that  he  regards  it  as  practicable  to  determine  the  size 
of  the  head,  its  position,  degree  of  flexion,  and  manner  of  engagement,  in  the 
latter  months  of  pregnancy.  No  shadow  can  be  obtained  of  the  spine  and 
limbs,  however.  Varnier's  J  complete  studies  have  not  yet  appeared,  and  although 
he  has  demonstrated  to  me  personally  in  Paris  the  minute  technique  of  his 
method,  I  do  not  feel  at  liberty  to  publish  it. 


XI.  THE  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY. 

Prophylaxis. — A  large  proportion  of  the  women  who  apply  to  the  gynecologist 
for  relief  of  crippled  pelvic  organs  owe  their  invalid  conditions  to  mismanagement 
or  avoidable  accidents  of  the  pregnant,  parturient,  and  lying-in  states.  This 
large  class  of  invalids,  who  owe  their  condition  to  careless  and  unclean  obstetrics, 
can  be  greatly  reduced,  if  not  practically  done  away  with,  and  the  remedy  is 
to  be  found  not  in  the  preaching,  but  in  the  practice  of  clean  and  conservative 
obstetrics.     A  careful  attention  to  prophylaxis,  on  the  part  of  the  obstetrician, 

*  "  Lehrbuch  d.  Rontgen-Untersuchung." 

t  "Ann.  de  Gyn6col.  et  d'0bst6triqiie,"  April,  1889. 

t  Professor  Varnier  died  in  1903. 


THE  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY.        185 

is  of  value  not  only  in  anticipating  and  warding  off  many  of  the  dangers  of 
pregnancy,  labor,  and  the  puerperium,  but  also  in  preventing  many  subsequent 
disabilities  of  a  gynecological  nature.  Nowhere  more  than  here  does  the  old 
maxim,  that  prevention  is  -better  than  cure,  find  truer  application.  There 
is  relatively  little  that  we  can  do  during  pregnancy,  which  will  have  a  direct 
influence  in  the  prevention  of  subsequent  uterine  and  pelvic  trouble.  Attention 
to  the  general  health,  however, — e.  g.,  the  prevention  of  constipation,  the 
proper  treatment  of  coexisting  anemia,  moderate  exercise  in  the  open  air, 
suitable  clothing,  especially  the  avoidance  of  constriction  about  the  waist,  in 
a  word,  a  good  hygiene  of  pregnancy, — is  undoubtedly  of  prophylactic  impor- 
tance in  two  ways:  (i)  By  providing  the  patient  with  healthy  blood,  one  of 
the  best  of  germicides,  and  thus,  perhaps,  forestalling  or  minimizing  the  effects 
of  septic  infection;  (2)  by  increasing  the  muscular  and  general  nutrition,  factors 
of  undoubted  importance  in  the  prevention  of  -subsequent  subinvolution  of 
the  uterus  and  adnexa.  Every  pregnant  woman  should  be  impressed  with 
the  importance  of  placing  herself  under  the  care  of  the  physician  who  is  to 
attend  her,  as  soon  as  she  shall  become  aware  of  her  condition.  It  would  be 
wise  to  give  such  a  patient,  early  in  gestation,  some  simple  directions,  either 
verbal  or  printed,  embracing  advice  regarding  exercise,  clothing,  diet,  care  of 
bowels,  skin,  kidneys,  breasts,  teeth,  and  the  danger-signals  of  approaching 
complications.  (See  Appendix.)  There  can  be  little  doubt  that  not  only  patients 
but  their  advisers  are  too  prone  to  consider  this  a  period  of  invalidism,  and 
to  forget  that  it  is  a  physiological  process.  One  of  the  important  results  of  the 
former  view  is  the  neglect  of  muscular  exercise,  especially  in  the  higher  ranks 
of  life,  where  the  desire  to  escape  observation,  and  the  fears  inspired  by  false 
ideas,  lead  to  the  neglect  of  even  the  little  exercise — i.  e.,  walking — to  which 
the  patient  is  accustomed,  and  the  consequent  weakening  of  the  whole  muscular 
system.  Now,  just  the  opposite  should  be  the  case.  The  strain  imposed  upon 
the  muscular  system  by  the  requirements  of  labor  is  a  severe  one,  and  should 
be  forestalled  by  the  cultivation,  as  far  as  possible,  of  muscular  strength.  In 
the  effort,  however,  to  secure  a  proper  hygiene  of  pregnancy,  we  should  not 
forget  the  danger  of  overexertion;  and  this  brings  us  to  the  consideration  of 
one  point  which  I  believe  to  be  of  especial  and  direct  prophylactic  importance. 
I  refer  to  the  avoidance  of  everything  which  increases  intrapelvic  pressure 
and  resulting  pelvic  congestion. 

No  one  who  has  had  an  extensive  obstetric  experience  can  jail  to  observe  that 
a  large  number  of  pregnancies  are,  when  carefully  studied,  really  pathological  in 
their  nature.  Witness  the  frequency  of  the  toxemia  of  pregnancy  as  we  understand 
the  condition  to-day,  and  the  probable  dependence  of  most  cases  of  vomiting  of 
pregnancy  upon  this  state.     (See  Part  III.) 

Our  present  knowledge  of  the  pregnant  state  demands  that  women  at  this  time 
shall  be  constantly  under  the  observation  of  a  competent  physician. 

Pregnancy  cannot  be  treated  through  the  m.ails  or  over  the  telephone. 

It  is  not  enough  that  a  monthly  or  bi-monthly  examination  of  the  urine  be  made 
for  symptoms  of  hepatic  or  renal  insufficiency,  as  such  urinary  analysis  often 
fails  completely  to  indicate  the  presence  of  toxemia. 

Pregnant  women  should  be  frequently  seen  by  their  physician,  and  watched  for 
general  symptoms  of  the  over-charging  of  the  blood  with  toxic  material — as  nausea 
and  vomiting,  headache,  physical  and  mental  lassitude,  high  arterial  tension, 
alterations  in  character  and  disposition. 

Thus,  and  thus  only,  shall  the  physician  do  his  whole  duty  by  his  patient. 

Exercise. — The  pregnant   woman  is   often   almost  unfitted   for    exercise  in 


186  PHYSIOLOGICAL  PREGNANCY. 

the  early  part  of  pregnancy,  on  account  of  the  usual  discomfort  of  "morning 
sickness,"  and  in  the  last  part  by  her  great  increase  in  size,  at  which  latter 
time  she  generally  lies  down  frequently  and  is  disinclined  to  any  exertion.  The 
nausea  of  the  early  months  often  plays  a  protective  role  in  pregnancy,  as  it 
demands  rest  on  the  part  of  the  patient,  who  might  otherwise  overexert  herself. 
Nevertheless,  a  moderate  amount  of  exercise  is  very  beneficial  during  the  period 
of  gestation;  walking  offers  the  most  favorable  form,  since  more  violent  exercise 
may  cause  much  harm.  Carried  to  the  point  of  slight  fatigue  every  day,  exercise, 
especially  walking,  will  put  the  woman  herself,  as  well  as  her  child,  into  the 
best  physical  condition  for  her  approaching  labor.  If  the  patient  is  unable 
to  take  this  kind  of  exercise,  then  the  passive  form  obtained 'in  carriage-driving 
will  be  found  next  in  order  of  efficiency;  but  if  this  causes  backache  and  a 
feeling  of  weight  in  the  lumbar  region  it  should  be  forbidden. 

Diet. — A  mixed  diet,  sufficient  in  quantity  to  meet  the  often  increased  appetite 
of  the  patient,  is  probably  the  best.  Important  modifications  of  diet  are,  of  course, 
imperative  in  threatened  albuminuria,  vomiting  of  pregnancy,  and  other  morbid 
conditions.  (See  Pathological  Pregnancy.)  Usually  early  in  pregnancy  there 
are  certain  digestive  disturbances  which,  with  the  less  active  life  they  entail, 
cause  a  decrease  in  desire  for  food.  In  many  cases  morning  sickness  has  been 
avoided,  or  at  least  lessened,  by  giving  an  early  morning  breakfast  to  the  patient, 
after  which  she  sleeps  for  an  hour  or  two  before  rising.  A  generous,  wholesome, 
and  simple  diet  is  demanded  by  the  patient.  Meats,  vegetables,  and  fruits  should 
be  included.  By  the  fourth  month  the  gastric  disorders  disappear,  as  a  rule,  and 
appetite  returns.  It  is  well,  during  the  last  of  gestation,  for  the  patient  to  take 
several  extra  lunches  daily,  and  on  account  of  the  encroachment  of  the  enlarging 
uterus  on  the  gastric  space,  the  amount  of  food  taken  at  one  time  should  be 
smaller,  but  the  intervals  between  meals  should  be  shorter. 

Drink. — The  drink  should  be  water,  milk,  or  chocolate;  tea  and  coffee  may 
be  taken  in  moderation,  but  should  not  be  strong.  Alcoholic  beverages  should 
be  avoided,  for  the  pregnant  woman  is  especially  prone  to  contract  the  alcoholic 
habit. 

Bowels. — The  bowels  should  be  carefully  looked  after,  and  constipation 
is  to  be  especially  avoided.  Plenty  of  water  should  be  taken  and  the  diet 
should  look  toward  the  alleviation  of  constipation.  Coarse  cereals,  fruit,  etc., 
encourage  free  movements.  Enemata  or  mild  laxatives  may  be  added  to  the 
regime.  Glycerin,  soap,  gluten,  and  cocoa-butter  suppositories  are  useful; 
one  or  two  teaspoonfuls  of  aromatic  cascara  at  bedtime ;  tasteless  fluid  extract 
of  cascara  and  fluid  extract  of  licorice  each  a  half-teaspoonful  at  bedtime; 
tablet  triturates  with  varying  combinations  of  aloin,  cascarin,  belladonna,  and 
strychnine.  The  habitual  use  of  suppositories  and  enemata  should  be  avoided, 
as  well  as  the  sulphate  of  soda,  mineral  waters,  or,  in  fact,  the  constant  use  of 
any  drug,  as  our  object  should  be  to  secure  proper  action  of  the  bowels  by 
attention  to  the  diet  and  the  free  use  of  water.  Most  pregnant  women  are 
benefited  by  an  occasional  dose  of  a  mercurial  at  bedtime,  followed  by  a  saline 
or  sulphur  water  in  the  morning.  (Compare  Constipation,  under  "Pathological 
Pregnancy.") 

Fresh  Air. — Plenty  of  outdoor  air  is  essential  to  the  patient.  The  gravid 
woman  is  eliminating  an  increased  amount  of  carbonic  acid,  as  she  is  breathing 
for  two.  Crowded  rooms  should  be  sedulously  avoided,  and  all  impure  air, 
sewer-gas,  etc.,  excluded.  There  must  be  thorough  ventilation  of  the  rooms  occu- 
pied both  by  night  and  day. 

Care  of  the  Skin. — The  skin  should  play  its  full  part  as  an  eliminating  organ. 


THE  HYGIENE  AND  MANAGEMENT  OF  PREGNANCY. 


187 


especially  in  the  last  part  of  pregnancy,  as  the  kidneys  must  be  relieved  as  far 
as  possible  of  extra  work.  Bathing  should  be  continued  according  to  the  patient's 
habits  before  pregnancy.  Reaction  may  be  secured  by  friction  with  a  coarse 
towel.  Hot  and  cold  baths, -however,  or  any  shock, — for  example,  that  incident 
to  sea-bathing, — should  be  avoided.  Tepid 
vaginal  douches  are  often  a  source  of  great 
comfort. 

Clothing. — Clothing  should  be  well  adapted 
to  the  condition.  Corsets  are  to  be  laid  aside; 
low-heeled  shoes  are  to  be  preferred;  it  is  well 
to  suspend  the  weight  of  the  garments  from  the 
shoulder-straps.  The  clothes  should  weigh  as 
little  as  possible  and  be  loosely  fitted.  Circular 
garters  ought  to  be  replaced  by  side  supporters. 
It  is  well  to  recommend  warm  drawers  as  soon  as 
the  enlarging  abdomen  lifts  the  skirts  from  the 
thighs.  If  the  abdomen  is  very  lax  and  pendu- 
lous, a  suitable  binder  may  well  be  applied  for 
support.  It  should  aim  to  lift  the  weight  from 
below  and  exert  no  pressure.  One  of  the  best 
abdominal  supporters  is  a  French  maternity  cor- 
set (Figs.  228  and  229),  which  combines  support 
of  the  lower  abdomen  with  that  of  the  breasts. 
I  had  this  corset  imported  several  years  ago, 
and  have  used  it  in  my  practice,  with  much 
satisfaction  to  my  patients.* 

Leucorrhea. — In  the  case  of  leucorrheal  dis- 
charge, vaginal  douches  may  be  necessary,  and 
bathing  and  care  of  the  external  genitals  are  ab- 
solutely demanded  for  the  comfort  of  the  mother. 
Local  treatment,  if  demanded,  can  be  applied 
without  harm,  with  proper  precautions,  (See 
Part  III.) 

Breasts. —  There  must  be  no  pressure  on  the 
mammary  glands,  and  they  must  be  warmly 
covered.  The  nipples  particularly  must  be  kept 
scrupulously  clean.  The  physician  should  make 
an  examination  of  these  organs  a  month  before 
labor,  when  any  abnormalities,  such  as  abrasions, 
fissures,  milk  scabs,  etc.,  can  be  treated.  If  the 
nipples  are  retracted,  they  may  be  drawn  out 
gently  every  day  by  the  patient  herself.  Some 
believe  in  the  daily  exposure  of  the  nipples  to 
the  air,  in  order  to  render  more  active  the 
epidermic  secretion.  To  prevent  sore  nipples 
during  lactation,  I  am  accustomed  to  instruct 

my  patients  to  carefully  draw  out  each  nipple  daily,  in  the  last  few  weeks  of 
gestation,  with  absorbent  cotton  moistened  with  an  oily  astringent,  such  as  com- 
pound tincture  of  lavender,  two  ounces,  and  glycerin,  half  a  drachm.  (For  breast 
supporters,  see  Pathological  Puerperium,  Part  VII.) 

*  This  maternity  corset  is  now  made  in  this  country  for  me  by  Mrs.  Leighton,  3  East 
41st  Street,  New  York  city. 


Fig.  228. — Ax  Improved  Ma- 
ternity Corset  for  Sup- 
port OF  THE  Lower  Abdomen 
AND  Breasts  in  the  Latter 
Weeks  of  Gestation.  An- 
terior View. — (From  a  pho- 
tograph taken  at  the  Emergency 
Hospital.) 


188 


PHYSIOLOGICAL  PREGNANCY. 


Mental  Condition. — Mental  depression  and  excitement  should  be  guarded 
against.  Anxiety  shoiild  be  quieted,  kind  assurances  and  encouragement  should 
not  be  spared.  The  patient  should  be  guarded  from  all  petty  worries  and  troubles, 
as  well  as  from  shocks  or  surprises.     Judicious  amusement  should  be  provided, 

and  she  should  be  surrounded  by  cheerful  and 
agreeable  companions,  while  her  mind  should 
be  occupied  by  some  pleasant  and  congenial 
occupation.  The  influence,  moral,  mental,  phy- 
sical, of  the  mother  on  the  fetus  in  titer o  is  a 
subject  so  vast  and  complex  that  its  depths 
have  never  yet  been  sounded.  Great  allow- 
ance should  be  made  for  the  whims  and  irri- 
tability of  the  pregnant  woman,  as  she  is 
often  not  responsible  for  her  altered  temper. 
Many  changes  in  her  are  probably  due  to  the 
alterations,  both  quantitative  and  qualitative, 
in  her  blood  at  this  time,  as  well  as  to  the 
changes  taking  place  in  her  sexual  organs.  So 
she  should  be  humored  and  shielded,  and  her 
idiosyncrasies  should  be  gently  overlooked. 

Examination  of  the  Urine. — From  the  third 
to  the  seventh  month,  monthly  examinations  of 
the  urine  should  be  made;  from  the  seventh 
to  the  ninth  month,  every  two  weeks,  and  then 
once  a  week  till  labor  begins.  The  patient  should 
be  warned  to  make  an  immediate  report  of  any 
decrease  in  the  amount  of  urine  excreted  in  the 
twenty-four  hours.  The  examination  should 
take  account  of  the  twenty-four  hours'  amount, 
/  .  / '        '''*.''^^c^^        ^^®  specific  gravity,  the  quantity  of  urea  and 

r  °""'7rl;:.:  /  j£^.       \:^)r^       its  variation,  intestinal  or  hepatic  toxemia,  and 

the  presence  of  albumin  and  casts.  Through 
this  constant  watch  for  symptoms  of  toxemia 
many  cases  of  eclampsia  may  be  avoided.  (See 
Toxemia  of  Pregnancy.) 

Sexual  Intercourse. — The  subject  of  marital 
intercourse  during  pregnancy  has  received  much 
attention.  Many  and  diverse  opinions  have 
been  expressed,  but  it  is  generally  considered 
that  during  the  first  months  of  pregnancy,  and 
at  the  last,  sexual  intercourse  should  be  forbid- 
den. To  most  pregnant  women  it  is  distasteful, 
although  in  others  the  sexual  appetite  is  in- 
creased. It  often  causes  great  pelvic  discom- 
fort. It  should  in  any  case  be  forbidden  at 
those  times  which  correspond  with  the  menstrual 
epochs,  as  then  pelvic  congestion  and  a  special 
tendency  to  abortion  exist.  Sexual  intercourse  is  held  to  be  one  of  the  most 
influential  factors  in  producing  abortion  and  systemic  disturbances. 

The  possibility  of  infection  of  the  uterus  during  coitus  from  germs  beneath 
the  foreskin  cannot  be  denied.  This  is  especially  liable  to  occur  in  a  case  of 
placenta  prsevia. 


Fig.  229. — An  Improved  Ma- 
ternity Corset  for  Support 
OF  THE  Lower  Abdomen  and 
Breasts  in  the  Latter 
Weeks  of  Gestation.  Pos- 
terior View. — (From  a  photo- 
graph taken  at  the  Emergency 
Hospital.) 


PART  THREE. 
Pathological   Pregnancy* 


I.  DISEASES  OF  THE  DECIDU/E.  (Page  191.)  1.  Acute  Infectious  or  Ex= 
anthematous  Deciduitis.  2.  Acute  Hemorrhagic  Deciduitis.  3.  Acute  Puru- 
lent Deciduitis.  4.  Chronic  Catarrhal  Deciduitis,  Endometritis  Gravidarum 
Catarrhalis,  Endometritis  Deciduae  Catarrhalis.  5.  Chronic  Diffuse  Hyper- 
plastic Deciduitis,  Endometritis  Deciduae  Chronica  Diffusa,  Endometritis 
Gravidarum  Hyperplastica.     6.  Chronic  Tuberous  or  Polypoid  Deciduitis. 

7.  Chronic  Cystic  Deciduitis.  8.  Apoplexy  of  the  Decidua.  9.  Atrophy 
of  the  Decidua.      10.   Deciduoma.      11.  Chorio-epithelioma  Malignum. 

II.  DISEASES  OF  THE  CHORION.  (Page  198.)  1.  Cystic  Degeneration  of  the 
Chorionic  Villi;  Hydatidiform  or  Vesicular  Mole ;  2.  Flbromyxomatous  De- 
generation of  the  Chorion.     3.  Chronic  Choriitis. 

III.  ANOMALIES  OF  THE  AMNION  AND  LIQUOR  AMNII.     (Page  201.)      1. 

Plastic  Exudation,  Amniotitis.  2.  Abnormal  Tenuity.  3.  Cysts  and  Der- 
moids. 4.  Premature  Rupture,  Amniotic  Hydrorrhea.  5.  Anomalies  in 
Color  and  Composition  of  Liquor  Amnii.  6.  Oligohydramnios.  7.  Hy= 
dramnios. 

IV.  ANOMALIES  AND  DISEASES  OF  THE  PLACENTA.     (Page  208.)      1.  Ano- 

malies.— (1)  Size:  (a)  Atrophy;  (b)  Hypertrophy;  (c)  Placenta  Membra- 
nacea.  (2)  Form.  (3)  Number,  (4)  Relation.  (5)  Insertion :  Placenta 
Praevia.  2.  Injuries. — Premature  Detachment.  Accidental  Hemorrhage. 
3.  Stasis  and  CEdema.  4.  Interstitial  Hemorrhage. — Apoplexy.  Infarc- 
tion. Thrombosis.  5.  Placentitis. — (1)  Acute  Septic,  (2)  Gonorrheal,  (^3) 
Emanuel's  Disease.  (4)  Specific;  (5)  Chronic  Interstitial  and  (6)  Albumm- 
uric.  6.  Infectious  Qranulomata. — Tuberculous  and  Syphilitic.  7.  Sec- 
ondary Metamorphoses. — (1)  Progressive.  Hyperplastic  and  Sclerotic. 
Adherent  Placenta.  (2)  Regressive.  Results  of  Fetal  Death.  White  In- 
farcts. Cystic,  Calcareous,  Fatty,  and  Miscellaneous  Degenerations.  8. 
Tumors. — -Placentomata.     Polypi. 

V.  ANOMALIES  OF  THE  UMBILICAL  CORD.  (Page  237.)  1.  Length.  2. 
Thickness.     3.  Insertion.     4.  Coils.     5.  Knots.     6.  Tangling.     7.  Torsion. 

8.  Stenosis  of  the  Vessels.     9.  Cysts.     10.  Calcareous  Deposits.     11.  Hernia. 

12.  Syphilis.  13.  Obstruction  of  the  Vessels.  14.  Dilatation  of  the  Um- 
bilical Vein.      15.  Hypertrophy  of  the  Valves.      16.  Congenital  Tumors. 

VI.  DEFORMITIES  AND  MONSTROSITIES  OF  THE  FETUS.     (Page  244.) 

VII.  ANTENATAL  DISEASES  OF  THE  FETUS.  (Page  255.)  I.  Infectious  Dis- 
eases. 2.  Acute  Poisoning.  3.  Chronic  Poisoning.  4.  Dyscrasic  Condi- 
tions. 5.  Cardiac  Diseases.  6.  Diseases  of  the  Alimentary  Tract.  7.  Dis- 
eases of  the  Nervous  System.     8.  Diseases  of  the  Urogenital  Apparatus. 

9.  Skin  Diseases.      10.  Bone  Disease.      11.  Traumatisms.      12.  Neoplasms. 

13.  General  CEdema.  14.  Maternal  Traumatisms.  15.  Maternal  t Uterine 
Disease  Affecting  the  Fetus.  16.  Fever  in  the  Mother  Affecting  the  Fetus. 
17.  Death  of  the  Mother  Affecting  the  Fetus. 

VIII.  DEATH  OF  THE  FETUS.    (Page  272.)     1.  Maceration.     2.  Mummification. 
3.  Absorption.     4.  Putrefaction.     5.  Saponification.     6.  Calcification. 

IX.  DISEASES  OF  THE  GENITAL  ORGANS.  (Page  274.)  1.  Anteflexion  and 
Anteversion.  2.  Retroflexion,  Retroversion,  and  Incarceration.  3.  Latero- 
flexion  and  Lateroversion.  4.  Prolapse  of  the  Pregnant  Uterus.  5.  Tor- 
sion. 6.  Hernial  Protrusion  of  the  Pregnant  Uterus.  7.  Periuterine  In- 
flammation and  Adhesion.  8.  Rheumatism  of  the  Uterine  Muscle.  9. 
Metritis.  10.  New  Growths  of  the  Uterus.  11.  Spontaneous  Rupture. 
12.  Malformations.  13.  Leucorrhea.  14.  Cystic  Vaginitis.  15.  Specific 
Vaginitis.  16.  Prolapse  of  the  Vagina.  17.  Pruritus  Vulvae.  18.  Vari- 
cosities of  Vagina  and  Vulva.      19.  Vegetations.     20.  CEdema  of  the  Vulva. 


21.  Eczema  of  the  Nipple.     22.  Mammary  Abscesses.     23.   Hemorrhage 
from  the  Genitals  during  Pregnancy.     24.  Hematoma  of  the  Vulva. 

X.  THE  TOXEMIA  OF  PREGNANCY.  AUTO=TOXEMIA  OF  PREG- 
NANCY. HEPATIC  INSUFFICIENCY.  PREGNANCY  LIVER.  PRE- 
ECLAMPTIC STATE.  (Page  291.)  1.  Toxemia  of  Pregnancy.  2.  Nausea 
and  Vomiting.     3.  Icterus.     4.  Convulsions  and  Coma.     5.  Eclampsia. 

XI.  DISEASES  OF  THE  URINARY  TRACT.  (Page  315.)  1.  Passive  Con= 
gestion  of  the  Kidney.  2.  Acute  Nephritis.  3.  Chronic  Nephritis.  4. 
Floating  Kidney;  Tumors  of  the  Kidney.  5.  Pyelonephritis.  6.  Hydro= 
nephrosis.  7.  Renal  Calculi.  8.  Renal  Insufficiency  and  Toxemia.  9. 
Vesical  Irritation.  10.  Cystitis.  1 1.  Incontinence  of  Urine.  12.  Urinary 
Retention.  13.  Vesical  Hemorrhoids.  14.  Vesical  Calculi.  15.  Cystocele. 
16.  Vesical  Neoplasms  and  Traumatism.  17.  Albuminuria.  18.  Polyuria. 
19.  Peptonuria.  20.  Hematuria.  21.  Glycosuria.  22.  Lipuria  and  Chy- 
luria.     23.  Acetonuria.     24.  Urinary  Sediments  of  Pregnancy. 

XII.  DISEASES  OF  THE  ALIMENTARY  TRACT.  (Page  321.)  1.  Gingivitis. 
2.  Dental  Caries.  3.  Oral  Sepsis.  4.  Salivation  or  Ptyalism.  5.  Anorexia. 
6.  Nausea  and  Vomiting.  7.  Persistent  Vomiting,  Hyperemesis  Gravi- 
darum. 8.  Malacia,  Longings.  9.  Gastric  and  Intestinal  Indigestion.  10. 
Consumption.  11.  Diarrhea.  12.  Hemorrhoids.  13.  Jaundice,  Icterus 
Gravidarum.     14.  Appendicitis.     15.  Tapeworm. 

XIII.  DISEASES  OF  THE  CIRCULATORY  SYSTEM.  (Page  325.)  1.  Acute 
Endocarditis.  2.  Chronic  Endocarditis.  3.  Affections  of  the  Heart  Mus= 
cle.  4.  Graves's  Disease.  5.  Varicosities.  6.  Aneurysm.  7.  Palpita- 
tion. 8.  Syncope.  9.  Hydremia.  10.  Pernicious  Anemia.  11.  Exoph- 
thalmic Goiter. 

XIV.  DISEASES  OF  THE  RESPIRATORY  SYSTEM.  (Page  329.)  1.  Hyper- 
osmia.  2.  Bronchitis.  3.  Pneumonia.  4.  Emphysema.  5.  Pleurisy. 
6.  Hemoptysis.  7.  Pulmonary  Tuberculosis.  8.  Acute  Miliary  Tuber- 
culosis. 9.  Dyspnea  of  Pregnancy.  10.  Neuroses  and  Spasmodic  Cough. 
11.  Asthma. 

XV.  DISEASES  OF  THE  NERVOUS  SYSTEM.  (Page  332.)  1.  Cerebral  Dis- 
ease. 2.  Gestational  Melancholia,  Mania,  and  Dementia.  3.  Vertigo  and 
Syncope.  4.  Insomnia.  5.  Gestational  Paralysis.  6.  Gestational  Neu- 
ralgias.    7.  Neuroses. 

XVI.  INFECTIOUS  DISEASES.  (Page  336.)  1.  Variola.  2.  Scarlatina.  3. 
Measles.  4.  Typhoid.  5.  Typhus.  6.  Erysipelas.  7.  Malaria.  8.  Pneu- 
monia.    9.  Syphilis. 

XVII.  SKIN  DISEASES.  (Page  337.)  1.  Pruritus.  2.  Pigmentation.  3.  Herpes 
Gestationis.  4.  Impetigo  Herpetiformis.  5.  Alopecia.  6.  Fibroma  Mol- 
luscum  Gravidarum. 

XVIII.  DISEASES  OF  THE  OSSEOUS  SYSTEM.  (Page  340.)  1.  Relaxation  of 
the  Pelvic  Joints.  2.  Inflammation  of  the  Joints.  3.  Osteomalacia.  4. 
Rachitis. 

XIX.  THE  PREMATURE  INTERRUPTION  OF  PREGNANCY.     (Page  342.) 

XX.  ECTOPIC  GESTATION.     (Page  361.) 

XXI.  PREGNANCY  IN  ONE  HORN  OF  A  UTERUS  UNICORNIS  OR  BI- 
CORNIS.      (Page  367.) 

XXII.  MISSED  LABOR.     (Page  368.) 

XXIII.  SUDDEN  DEATH  DURING  PREGNANCY.     (Page  369.) 

|XXIV.  INJURIES  AND  OPERATIONS  UPON  PREGNANT  WOMEN.    (Page  369.) 

XXV.  PREGNANCY  AFTER  OPERATIONS  INVOLVING  THE  GENITALS. 
(Page  370.)  Pregnancy  after  Ventro=fixation  and  Ventro=suspension. 
(See  Pathological  Labor,  page  600.) 

XXVI.  THE  FEVER  OF  PREGNANCY.     (Page  370.) 

XXVII.  THE  METRORRHAGIA  OF  PREGNANCY.     (Page  371.) 


Pathological  or  abnormal  pregnancy  is  one  in  which  some  departure  from  a 
physiological  pregnancy  occurs  in  mother,  ovum,  embryo,  or  fetus.  Although 
the  vast  majority  of  pregnancies  are  normal,  still  it  must  be  remembered  that 
in  all  classes  of  mankind  the  departures  from  the  normal  standard  in  ances- 
tors and  parents,  with  their  accompanying  physical  imperfections,  latent  or 
obscure  though  they  may  be,  will  show  themselves  in  even  more  pronounced 
and  dangerous  forms  in  the  pregnant  womail  and  the  fetus  in  utero.  The 
influences  upon  the  present  and  subsequent  generations  of  years  of  improper 
hygienic  environment  and  nutrition,  with  their  resulting  faulty  development 
of  muscle  and  bone,  and  reflex  neuroses  must  never  be  lost  sight  of  in  the 
examination  of  pregnancy. 


I.  DISEASES  OF  THE  DECIDU/E. 

;•.  Acute  Infectious  or  Exanthematous  Deciduitis.  2.  Acute  Hemorrhagic  Deciduitis,  j. 
Acute  Purulent  Deciduitis.  4.  Chronic  Catarrhal  Deciduitis,  Endometritis  Gravidarum 
Catarrhalis,  Endometritis  Deciduce  Catarrhalis.  5.  Chronic  Diffuse  Hyperplastic 
Deciduitis,  Endometritis  Deciduce  Chronica  Diffusa,  Endometritis  Gravidarum  Hyper- 
plastica.  6.  Chrome  Tuberous  or  Polypoid  Deciduitis.  7.  Chronic  Cystic  Deciduitis. 
8.  Apoplexy  of  the  Decidua.  g.  Atrophy  of  the  Decidua.  10.  Deciduoma.  11.  Chorio- 
epiihelioma  Malignum. 

Introduction. — The  decidua  is  the  transformed  endometrium,  and  it  is  sub- 
ject to  any  of  the  diseases  that  may  attack  the  non-gravid  uterine  mucous 
membrane;  but  in  the  case  of  pregnancy  these  affections  are  apt  to  assume 
a  severe  grade,  owing  to  the  great  hypertrophy  of  the  tissue  concerned.  The 
results  are  apt,  also,  to  be  more  serious,  on  account  of  the  relation  to  the  fetus. 
Endometritis,  so  called,  is  generally  not  inflammatory,  so  the  term,  as  often 
applied,  is  a  misnomer.     These  diseases  are  of  several  forms. 

I.  Acute  Infectious  or  Exanthematous  Deciduitis. — As  its  name  impHes,  this 
is  generally  a  result  of  the  acute  infectious  diseases,  although  it  may  be  an 
extension  of  an  inflammation  from  the  endometrium  before  pregnancy.  Ahlfeld 
declares  that  the  cervix  is  nearly  always  infected  first,  and  this  can  be  clearly  seen 
if  the  decidua  serotina  lies  near  the  cervix,  as  in  placenta  prasvia.  Of  great 
interest  are  the  eleven  cases  of  Klotz,  which  show  the  effect  of  measles[on  preg- 
nancy. Nine  of  these  suffered  from  abortion,  at  a  time  which  seemed  to  show  a 
direct  connection  between  the  expulsive  efforts  of  the  uterus  and  the  breaking- 
out  of  the  eruption  on  the  skin.  Klotz  believes  that  the  uterine  contractions 
are  caused  by  the  irritation  of  the  exanthem  as  it  occurs  on  the  mucous  mem- 
brane of  the  uterus.  This  disturbance  is  analogous  to  the  photophobia,  coryza, 
bronchitis,  and  vesical  tenesmus,  which  are  the  expression  of  the  effect  of  the 
same  irritating  cause  upon  other  mucous  membranes.  The  same  explanation 
would  probably  hold  good  for  abortions  occurring  in  any  of  the  eruptive  fevers. 
This  condition  consists  in  active  inflammatory  changes,  which  may  involve  only 
small  foci  or  the  entire  decidua. 

191 


192  PATHOLOGICAL  PREGNANCY. 

2.  Acute  Hemorrhagic  Deciduitis. — In  deciduse  may  often  be  found  old  and 
fresh  extravasations  of  blood  between  the  villi.  In  one  variety  tuberosities 
form,  much  like  those  seen  in  the  tuberous  decidua.  If  the  extravasation  con- 
tinues after  the  death  of  the  fetus,  there  is  finally  formed  what  is  known  as  a 
"fleshy  mole."  This  structure  conforms  to  the  shape  of  the  uterine  cavity, 
and  consists  of  various  layers  of  blood  of  different  hemorrhages,  held  together 
by  means  of  the  atrophied  villi.  In  the  center  of  this  mass  we  usually  find  the 
empty  amniotic  cavity,  but  at  times  the  macerated  fetus  is  present.  (Compare 
Pathology  of  Interrupted  Pregnancy.) 

3.  Acute  Purulent  Deciduitis. — This  condition  is  very  rare.  The  case  de- 
scribed by  Donat  shows  the  state  of  the  structures  concerned.  This  patient 
expelled  at  term  a  placenta  which  was  surrounded  by  a  margin  of  decidual 
tissue  infiltrated  with  pus.  Between  the  amnion  and  chorion,  which  were  both 
thickened  and  -opaque,  was  a  mass  of  purulent  liquid.  This  condition  probably 
resulted  from  an  unsuccessful  abortion  attempted  by  the  woman  herself.  Various 
explanations  have  been  offered  to  clear  up  the  nature  of  the  case.  Donat  him- 
self thinks  that  the  pus  made  its  way  from  the  decidua  through  the  chorion, 
collecting  between  the  latter  membrane  and  the  amnion.  Careful  macroscopic 
and  microscopic  examinations  were  made,  dispelling  all  doubt  about  the  case. 
Hirst  suggests  that  the  pus  might  have  been  originally  expressed  from  a  dis- 
tended tube.  Thence  it  may  have  forced  its  way  through  the  ovular  decidua, 
or,  if  ealrlier  in  pregnancy,  through  the  layers  of  the  membranes.  This  last 
theory  seems  quite  plausible,  in  consideration  of  the  recent  work  done  on  hydror- 
rhoea  ovarialis  intermittens,  in  which  affection  there  is  a  periodic  discharge 
from  the  tube  into  the  uterus. 

4.  Chronic  Catarrhal  Deciduitis;  Endometritis  Gravidarum  Catarrhalis;  En- 
dometritis Deciduae  Catarrhalis;  Hydrorrhoea  Gravidarum. — Definition. — This  is 
a  chronic  inflammation  of  the  decidual  endometrium,  probably  arising  from 
some  obscure  morbid  condition  of  the  mucous  membrane. 

Pathology. — Many  theories  have  been  advanced  to  explain  this  rare  condi- 
tion. It  may  arise  from  a  hypertrophy  of  the  glands,  whose  openings  are  not 
obliterated;  and,  as  a  result  of  this  state  of  chronic  glandular  inflammation,  a 
clear  viscid  liquid  is  poured  out  between  the  decidua  and  chorion,  whence  it 
makes  its  escape  to  the  os  uteri.  The  secretion  varies  greatly  in  quantity;  in 
one  reported  case,  from  one-half  to  three-quarters  of  a  liter  was  lost  each 
time.  Some  believe  that  the  secretion  comes  from  the  bursting  of  a  cyst  which 
is  formed  between  the  ovum  and  the  uterine  walls;  others,  that  it  is  a  transu- 
dation of  the  liquor  amnii  through  the  membranes.  Another  suggestion  is  that 
the  liquid  escapes  from  an  opening  in  the  membranes  at  a  distance  from  the 
OS  uteri ;  still  another,  that  the  liquid  comes  from  a  sac  between  the  amnion  and 
chorion.  In  these  last  cases  there  may  be  only  one  gush  of  the  liquid  contents ; 
but  if  the  discharge  is  a  continuous  one,  or  repeated  intermittently,  none  of 
these  theories  will  hold  good.  This  affection  occurs  in  the  first  part  of  preg- 
nancy, before  the  refiexa  joins  the  vera;  if,  however,  this  union  does  not  take 
place,  the  discharge  may  continue  throughout  pregnancy. 

Symptoms. — The  fluid,  which  is  of  a  pale  yellowish  color  and  transparent, 
may  escape  from  the  vagina  by  dribbling,  or  by  one  sudden  gush.  It  may 
escape  from  time  to  time  for  weeks,  and  in  such  quantity  as  to  soak  the 
clothing  of  the  patient. 

Diagnosis. — If  a  physician  is  called  to  such  a  case,  and  is  told  that  there 
has  been  an  escape  of  waters,  he  is  apt  to  think  that  the  membranes  have  been 
ruptured.     In  hydrorrhea   there  are  no   pains,  the  cervix  is    not  dilated,  and 


DISEASES   OF   THE   DEC  I  BUM. 


193 


Fig.  230. — Decidual  Endometritis,  i,  Decidual 
tissue;  2,  fetal  villi;  3,  layer  of  pus.  (X  250 
diameters  ) — {From  a  specimen  in  the  Pathologi- 
cal Laboratory  of  the  Cornell  University  Medical 
College.) 


ballottement  can  be  obtained.  If  after  the  watery  discharge  pregnancy  con- 
tinues as  before,  the  diagnosis  of  hydrorrhea  may  be  estabhshed.  Pregnancy 
often  continues  to  term  with  no  'untoward  phenomena. 

Differential  Diagnosis. — Hydrorrhoea  gravidarum  is  distinguished  from  incon- 
tinence of  urine  also  by  the  na- 
ture of  the  secretion,  and  by  the 
absence  of  urea  and  of  acid  re- 
action. Endotrachelitis  and  col- 
pitis are  excluded  by  inspection, 
and  by  the  absence  of  pus.  Pus 
may  occur,  however,  if  the  dis- 
ease is  accompanied  by  an  endo- 
metritis. 

Prognosis. — In  general,  the 
prognosis  is  good  for  both 
mother  and  child,  as  the  preg- 
nancy is  not  compromised  by 
the  disease.  The  child  should 
be  born  at  term  and  in  good 
condition.  If  other  causes  of 
abortion  are  operative,  the  ges- 
tation may  of  course  be  inter- 
rupted. When  the  discharge  is 
continuous  and  of  a  dark  hue, 
the  case  may  not  go  on  to  term. 
Treatment.  —  The  manage- 
ment is  comprised  in  the  pro- 
phylaxis of  abortion.  The  woman  should  be  kept  recumbent,  even  in  cases 
of  moderate  degree.  Opiates  should  be  administered  if  uterine  contractions  are 
present. 

5.  Chronic  Diffuse  Hyperplastic  Deciduitis;  Endometritis  Deciduae  Chronica 

Diffusa;  Endometritis  Gravi- 
darum Hyperplastica. — Defi- 
nition.— Instead  of  the  atro- 
•phy  of  the  uterine  mucous 
membrane  that  normally 
takes  place  in  the  latter  part 
of  pregnancy,  the  condition  of 
hyperplasia  that  existed  in 
the  first  part  continues  to 
increase  (Fig.  230). 

Pathology. — This  steady 
progression,  which  aflfects 
both  layers  of  the  decidua, 
results  in  a  membrane  |-  or 
^  inch  (3  or  4  mm.)  in  thick- 
ness. The  cells  increase  in 
size,  and  have  larger,  more  vesicular  nuclei.  The  tissue  looks  like  that  of  a 
sarcoma,  and  has  been  described  as  such.  If  the  disease  makes  rapid  strides, 
abortion  will  generally  occur  as  a  result  of  hemorrhages  into  the  mucous  mem- 
brane, which  separate  it  from  the  wall  of  the  uterus.  Or  it  may  occur  from  the 
death  of  the  fetus,  whose  nourishment  has  all  been  diverted  to  the  increase  of 
13 


Fig. 


231- 


-Decidua  Tuberosa  from  an  Abortion. - 
{Ahljeld.) 


194 


PATHOLOGICAL  PREGNANCY. 


the  decidua.  The  embryo  may  be  absorbed,  and  the  decidual  membranes  after- 
ward discharged  as  an  empty  sac  with  very  thick  walls,  in  which  case  it  consti- 
tutes one  variety  of  the  fleshy  moles,  (See  Abortion.)  Or  the  embryo  may  be 
destroyed  by  hemorrhages  into  the  abnormally  developed  decidua,  the  blood 
forcing  its  way  through  all  obstructions  into  the  cavity  of  the  ovum.  In  this 
condition  only  microscopic  examination  will  reveal  the  true  character  of  the 
tissues.  New-formed  muscle-fibers  have  been  seen  in  the  hypertrophic  tissues. 
The  etiology  of  this  affection  is  generally  an  antecedent  morbid  condition  of  the 
mucous  membrane,  which  the  presence  of  the  fecundated  ovum  excites  to  ab- 
normal proliferative  activity.  The  morbid  condition  is  actually  a  chronic  endo- 
metritis, either  simple,  syphilitic,  or  gonorrheal.  Similarly,  the  death  of  the  em- 
bryo, or  some  disease  of  the  latter,  may  ex- 
cite the  previously  healthy  mucous  mem- 
brane to  overgrowth. 

Prognosis. — The  danger  to  the  mother 
lies  in  the  frequent  retention  in  utero  of  rem- 
nants of  the  placenta,  which  are  not  expelled 
with  the  rest  of  the  ovum.     Frequently  the 


i-b 


Fig.  232. — Polypoid  Degeneration  of  the  De- 
cidua Vera.  The  upper  figure  is  a  section  of  one 
of  the  polypoid  growths  enlarged,  showing  blood- 
vessels at  a  and  decidual  cells  at  b. — {Veil.) 


Fig.  233. — Tuberous  Subchorial 
Hematomata  of  the  Decidua. — 
{Walther.) 


decidua  over  the  placental  site  is  retained,  giving  rise  to  hemorrhages  or  septi- 
cemia. This  condition  has  been  described  under  various  names  by  different 
authorities. 

6.  Chronic  Tuberous  or  Polypoid  Deciduitis. — This  disease  of  the  decidua 
was  first  described  by  Virchow,  who  thought  it  syphilitic  in  origin,  since  his  case 
exhibited  a  syphilitic  history  (Figs.  231,  232,  and  233).  Later  work,  however, 
shows  no  evidence  that  the  disease  is  due  to  syphilis,  and  no  assignable  cause 
has  thus  far  been  discovered. 

Pathology. — This  is  a  hyperplastic  affection,  and  corresponds  to  hyperplasia 
in  the  non-pregnant  condition,  so  that  the  etiology  of  this  form  of  deciduitis 
must  be  traced  to  a  pre-existing  chronic  endometritis.  The  disease  belongs 
to  early  ova,  and  quite  often  the  chorionic  villi  are  seen  to  have  undergone 
myxomatous  degeneration.  Schroeder  states  that  in  all  the  cases  so  far  de- 
scribed, abortion  has  occurred  between  the  end  of  the  second  month  and  the 
beginning  of  the  fourth.  Ahlfeld  says  that  this  condition  is  frequently  seen  in 
aborted  ova.     The  internal  surface  of  the  decidua  is  studded  with  villus-like 


DISEASES   OF  THE  DECIDUM.  195 

projections,  which  measure  half  an  inch  (1.25  cm.)  or  more  in  height  (Fig.  232). 
They  are  polypoid  nodules  or  cones,  very  vascular,  and  possess  a  smooth  sur- 
face. Between  these  nodes  may  be  seen  the  openings  of  the  glands,  which  do 
not  appear  at  all  upon  the  projections.  The  entire  membrane  is  much  thickened, 
and  consists  of  proliferated  connective  tissue,  and  hypertrophy  of  the  decidual 
cells,  with  enlargement  of  the  nuclei.  Although  the  surface  is  by  some  described 
as  smooth,  others  characterize  it  as  rough  and  covered  with  coagulated  blood. 
Bulius,  of  Freiburg,  has  done  much  work  in  this  field.  Sections  show  decidual 
cells  with  a  little  glandular  tissue.  The  fibrous  bundles  of  connective  tissue 
constrict  the  gland  openings  and  blood-vessels.  Yet,  in  spite  of  this,  the  entire 
decidua  is  extremely  vascular. 

7.  Chronic  Cystic  Deciduitis,  or  Endometritis  Deciduae  Cystica  (Fig.  234). — 
This  affection  is  rare,  but  has  been  observed  by  Hegar  and  Breus.  It  resem- 
bles the  last  form,  endometritis  polyposa,  except  that  the  fibrous  elevations 
are  not  masses  of  decidual  cells,  but  consist  of  cystic  gland  cavities  which  con- 
tain liquid.  They  are  retention-cysts,  formed  by  occlusion  of  the  glands  of  the 
uterine  ducts.     This  condition  is  found  only  in  very 

young    ova.     It    might  occur  in   the  first  stages  of 

chronic  hyperplastic  decidual  endometritis,  in  which  y^     ,   «.  V  rt''^ 
the  advancing  disease  destroys  and  later  obliterates  CI^  \'^  J<  -.  ^  k^^ 
the  glands.     About  the  retention-cysts  the  connec- 
tive tissue  is  hypertrophied,  and  embryonal  elements  _     , 
are  also  found,  together  with  an  increase  in  decidual  ^^^"' 

'^^^^'-  .  .  L^ 

Treatment   of  Decidual  Infian-ifnations . — In   preg-     ^^ 

nancy  the  treatment  of  these  chronic  forms  of  endo- 
metritis is  impossible,  the  only  resource  being  to  use 
prophylaxis,  by  treating  the  antecedent  chronic  endo- 
metritis that  is  almost  invariably  present.  <X 

8.  Apoplexy  of  the  Decidua. — We  have  alluded  to 
this  subject  under  hemorrhagic  endometritis.  The 
great  vascularity  of  the  deciduse  and  the  delicacy  of 

the  walls  of  the  vessels  predispose  these  tissues,  under  p  n 

the  influence  of  mild  traumatism,  to  effusion  of  blood,         eration  op  the  Decidua 
with  resulting  abortion.     Apoplexy  of    the   decidua         Vera. — {Breus.*) 
occurs  most  frequently  during  the  first  two  months 

of  pregnancy.  The  blood  collects  both  within  and  between  the  membranes. 
The  effusion  of  blood  may  extend  through  the  entire  thickness  of  the  deciduae 
(Fig.  235).  _ 

If  abortion  occurs  directly  after  the  effusion  of  blood,  the  whole  mass  dis- 
charged is  known  as  a  "blood "  or  "sanguineous  "  mole  (mola  sangiiinea).  But  if 
this  expulsion  occur  at  a  later  period,  there  is  time  for  the  organization  of  blood- 
clot,  which  gives  a  curious  raw-beef  appearance  to  the  mass,  which  is  then  called 
a  "  carneous  "  or  "  fleshy"  mole  {mola  carnosa).  (See  Abortion.)  If  a  deposi- 
tion of  lime  salts  take  place  in  the  clots,  as  it  rarely  does,  there  is  formed  a 
"calcareous"  or  "stone"  mole.  Pregnancy  coming  to  an  end  in  this  manner 
is  called  a  false  or  molar  pregnancy,  and  the  product  is  known  as  a  "blighted" 
ovum. 

The  etiology  of  apoplexy  of  the  decidua  consists  in  traumatisms  of  various 
kinds:  injuries,    blows,    repeated    congestions    from    too    frequent    coitus;   also 

*  "Arch,  fur  Gyn.,"  Bd.  XIX,  S.  486. 


196 


PA  THOLOGICAL  PREGNANC Y. 


Bright 's  disease,  the  decidiiae  sharing  in  the  general   tendency  to  congestion 
characteristic  of  this  disease. 

The  treatment  is  simply  that  of  abortion. 

9.  Atrophy  of  the  Decidua. — In  rare  instances  the  deciduae  atrophy  instead 
of  undergoing  hypertrophy  and  hyperplasia  (Fig.  236).  Hegar,  Matthews  Duncan, 
Spiegelberg,  and  Priestley  have  described  this  condition.  The  uterine,  ovular, 
or  placental  decidua  may  participate  in  this  change  either  singly  or  together. 
If  the  uterine  mucosa  is  affected,  the  ovum  does  not  find  a  sufficient  resting 
place  in  the  uterine  fundus.  It  stays  in  its  normal  site  until  it  becomes  too 
heavy  for  the  decidual  attachments.  These.it  gradually  pulls  into  a  long, 
slender  pedicle,  which  lodges  in  the  cervix.  It  increases  in  size  till  it  causes 
reflex  contractions  of  the  cervix,  being  in  this  manner  expelled  from  the  uterus. 
This  is  the  cervical  pregnancy  of  Rokitansky. 
If  the  ovular  decidua  is  affected,  there  is 
lacking  the  outermost  membrane  of  the 
ovum,  which  consequently  may  rupture  and 
its  contents  be  expelled  from  the  uterus. 

10.  Deciduoma. — Neoplasms  of  the  de- 
cidua are  very  rare.  Two  varieties  have 
been  described,  one  of  which  is  non-malig- 
nant and  the  other  malignant.  Deciduoma 
consists  of  the  remains  of    decidua    which 


Fig.    235.— Fleshy    Mole    (Mola    Carnosa). — 
(Ahlfeld.) 


Fig.  236. — Atrophy  of  the  Decidu.a. 
Y  ERA.— (Ahlfeld.) 


have  undergone  hyperplasia.  The  chief  symptoms  are  hemorrhage,  a  leucorrheal 
discharge  which  is  fetid  and  profuse,  with  now  and  then  fragments  of  decidual 
tissue.  There  are  elevated  temperature,  chilly  sensations,  and  prostration, 
showing  a  certain  amount  of  toxemic  disturbance.  There  is  only  an  insecure 
attachment  between  the  tumor  and  the  uterine  wall.  The  growth  should  be 
thoroughly  removed  by  the  curette.  Quinine,  ergot,  and  stimulants  are  indi- 
cated internally. 

II.  Chorio -epithelioma  Malignum. — Definition. — A  malignant  uterine  neo- 
plasm originating  from  the  decidual  tissues,  but  manifesting  itself  only  after 
the  termination  of  pregnancy,  whether  by  mole-formation,  abortion,  or  full- 
term  delivery,  and  including  ectopic  pregnancy. 

Pathology. — These  growths  have  been  regarded  respectively  as  deciduomata 
and  syncytial  growths  of  malignant  nature,  sarcomata,  epitheliomata,   and  car- 


DISEASES   OF  THE   DECIDUJE. 


197 


cinomata,  but  at  present  the  consensus  of  opinion  is  that  they  represent  an  epi- 
thelioma of  the  chorionic  tissue.  The  destructive  vesicular  mole,  while  at  times 
resembling  chorio-epithelioma,  is  held  to  be  a  different  condition,  but  transition 
forms  occur  in  which  differentiation  is  impossible.*  In  cases  in  which  the  de- 
structive mole  has  completely  invaded  the  uterus,  the  veins  of  the  latter  may  be 
occluded,  and  bits  of  villi  entering  the  circulation  may  cause  metastases  in  the 
lungs.  In  chorio-epithelioma,  on  the  other  hand,  the  metastases  are  numerous 
and  varied  in  site;  not  only  the  lungs,  but  the  brain  and  viscera  may  be  affected. 
Local  metastases  in  the  vagina  and  vulva  also  occur.  As  already  stated,  how- 
ever, transition  forms  are  encountered  which  render  hard  and  fast  distinctions 
difficult  or  impossible. 

A  striking  feature  of  true  chorio-epithelioma  is  that  it  may  consist  of  meta- 
stases alone,  i.  e.,  a  primary  focus  in  the  uterus  may  not  be  demonstrable. 
Another  not  less  remarkable  fact 
is  an  analogous  condition  in  the 
male,  in  which  embryonal  tu- 
mors in  the  testicle  not  only  re- 
semble deciduoma  in  the  partu- 
rient female  as  to  structure,  but 
are  attended  with  similar  meta- 
stases. This  fact  has  led  to  the 
belief  that  the  process  must  be 
something  more  than  an  acci- 
dent of  maternity. 

The  elements  of  the  chorio- 
epithelioma  are  derived  from 
the  epithelium  of  the  chorionic 
villi  alone,  or  from  both  the  epi- 
thelium and  stroma.  In  typical 
forms  the  original  arrangement 
of  the  chorionic  elements  is  pre- 
sented, while  in  atypical  forms 
it  is  lost.  All  transitions  be- 
tween the  two  forms  may  occur. 
In  the  typical  form,  the  morbid 
process  is  expressed  by  a  distinct 
tumor-formation,  while  in  atypi- 
cal forms  we  see  rather  a  diffuse 

infiltration  of  the  neighboring  tissues  by  the  chorionic  elements.  In  both  forms 
the  proliferating  cells  have  the  property  of  causing  the  formation  of  fibrin — a 
phenomenon  also  to  be  seen  in  the  normal  placenta  and  in  vesicular  mole. 

Symptomatology. — Chorio-epithelioma,  when  typical,  usually  begins  as  a 
small  tumor  in  the  uterine  cavity,  save  in  those  cases  in  which  a  primary  lesion 
cannot  be  demonstrated.  In  such  cases  the  process  is  probably  atypical,  the 
infiltrating  chorionic  cells  passing  into  the  circulation  without  the  formation  of 
a  nodule.  Under  such  circumstances,  the  first  lesion  noted  may  be  a  secondary 
vaginal  nodule.  Naturally,  we  find  no  symptoms  during  pregnancy,  and  unless 
we  are  dealing  with  a  uterine  mole,  we  do  not  find  any  clinical  association  of 
the  disease  with  the  post-gestational  period.  The  local  metastases,  i.  e.,  those 
connected  with  the  birth  tract,  should  appear  first,  in  the  form  of  nodular  growths 
in  the  vagina  or  vulva;  but  these  appear  so  long  after  the  termination  of  preg- 
*  Risel,  "  Ueber  das  maligne  Chorio-epitheliotn,"  Leipzig,  1903. 


Fig.  237. — Syncytioma  Malignum.  This  photo- 
graph shows  the  tip  of  a  fetal  villus  covered  with 
strands  and  masses  of  neoplastic  syncytium. 
(X  200  diameters).  (From  a  specimen  in  the 
Pathological  Laboratory  of  the  Cornell  University 
Medical  College). 


198  PATHOLOGICAL  PREGNANCY. 

nancy  that  they  hardly  belong  to  obstetric  practice.  Symptoms  of  visceral  meta- 
stases depend  upon  the  vital  organs  chiefly  attacked  (lungs,  brain,  etc.).  In 
case  of  numerous  metastases  death  occurs  under  the  usual  picture  of  general 
malignancy,  as  seen  in  the  metastatic  sarcoma  and  cancer. 

Diagnosis. — This  is  based  on  microscopic  study  of  the  vaginal  and  vulval 
tumors;  in  their  absence,  the  expulsion  of  a  mole  or  an  atypical  uterine  hemor- 
rhage should  be  regarded  with  suspicion,  and  the  uterus  should  be  curetted  and 
its  scrapings  examined. 

A  differential  diagnosis  between  chorio-epithelioma  and  destructive  vesicular 
mole  is  hardly  demanded. 

Treatment. — Since  the  metastases  are  often  limited  to  the  lower  genital  pass- 
ages, these  growths  should  always  be  extirpated  at  once.  If  the  uterus  appears 
healthy  and  yields  no  scrapings  suggestive  of  malignancy,  hysterectomy  may 
not  be  indicated,  as  a  primary  uterine  tumor  has  probably  failed  to  form.  But 
while  recovery  has  often  occurred  under  these  circumstances,  hysterectomy  done 
upon  exact  indications  usually  fails  to  save  life.  Hence,  there  must  be  transi- 
tion cases  in  which  the  indications  for  hysterectomy  cannot  be  laid  down. 
Spontaneous  recovery  from  chorio-epithelioma  has  been  recorded  a  number  of 
times. 


II.  DISEASES  OF  THE  CHORION. 

/.  Cystic  Degeneration  of  the  Chorionic  Villi.     Hydatidijorm  or  Vesicular  Mole.     2.  Fibro- 
myxomatous  Degeneration  of  the  Chorion,  j.  Chronic  Choriitis. 

I.  Cystic  Diseases  of  the  Chorion. — Synonyms. — Hydatidiform,  Hydatiform, 
Hydatoid,  Placental,  Vesicular,  or  Cystic  Mole;  Uterine  Hydatids;  Cystic  disease 
of  the  ovum ;  Hydatidiform  or  myxomatous  degeneration  of  the  chorionic  villi ; 
Cystic  degeneration  of  the  villi  of  the  chorion ;  Dropsy  of  the  villi  of  the  chorion ; 
Molar  pregnancy. 

Definition. — This  disease  consists  in  a  cystic  formation  at  the  ends  of  the 
villi,  giving  them  the  appearance  of  berries  or  grapes  (Fig.  240). 

Frequency. — The  disease  is  very  rare;  Madam  Boivin,  of  Paris,  found  it  but 
once  in  20,000  cases.  I  have  seen  it  four  times  in  15,000  cases  of  labor  observed 
in  hospital  and  private  practice.  It  is  oftenest  found  in  multiparae,  especially 
between  the  ages  of  twenty-five  and  forty.  It  is  characterized  by  the  tendency 
to  recur  in  the  same  patient  in  subsequent  pregnancies.  Mayer  has  reported 
eleven  cases  of  this  disease  in  one  patient.  Hydatidiform  mole  develops  usually 
in  the  first  few  months  of  pregnancy,  and  very  rarely  after  the  fourth  month. 
When  occurririg  within  the  first  four  weeks,  death  of  the  fetus  rapidly  follows ^ 
in  some  cases  with  complete  absorption.  If  the  development  is  later,  in  the 
second  or  third  month,  the  fetus,  although  it  may  die,  may  be  saved,  if  too 
much  of  the  membranes  and  placenta  is  not  involved.  If  the  death  of  the 
fetus  does  occur  at  this  period,  there  is  rarely  complete  absorption.  As  has 
been  stated,  the  disease  is  far  more  common  in  the  latter  part  of  the  woman's 
sexual  life;  according  to  some  authorities,  22  per  cent,  are  found  between  the 
ages  of  forty  and  sixty. 

Pathology. — In  the  formation  of  this  growth,  the  syncytium  and  Langhans*^ 
layer  of  cells  play  a  most  important  role,  and  appear  to  give  the  first 
impulse  toward  the  changes  in  the  villus.  Large  masses  of  syncytium  and 
chorionic   epithelium   bore   their   way  into   the    uterine    walls,    suggesting    a 


DISEASES  OF   THE  CHORION. 


199 


malignant  growth  (see  Chorio-epithelioma  Malignum).  Not  only  do  the  epi- 
thelial cells  proliferate,  but  also  the  connective  tissue  with  its  vessels.  The 
resultant  translucent  vesicles  contain  a  fluid  closely  resembling  the  liquor 
amnii,  and  in  size  they  range 'from  that  of  a  millet-seed  to  a  walnut.  The  mass 
in  toto  may  grow  as  large  as  a  man's  head,  absorbing  the  nourishment  intended 
for  the  fetus,  which  usually  dies,  while  the  mole  develops  over  the  whole  surface 
of  the  chorion  (Fig.  240).  The  arteries  of  the  degenerated  villi  become  obliter- 
ated, with  destruction  of  the  decidua.  Uterine  pains  begin,  as  a  rule,  in  the  fourth 
or  fifth  month.  At  times  the  mass  is  so  intimately  connected  with  the  uterus 
that  its  expulsion  is  very  difficult.  Sometimes  the  growth  erodes  the  great 
blood-vessels,  causing  fatal  hemorrhage.  The  vesicles  possess  the  same  form  as 
do  the  elements  of  the  original  chorion  of  the  first  two  months,  and  this  accounts 
for  the  peculiar  grape-  or  berry-like  appearance  of  the  tumor-mass.  Either  the 
whole  surface  of  the  chorion  is  covered  with 
these  cysts,  which  replace  the  villi,  or  only 
the  placental  region  is  affected.  The  former 
happens  when  the  mole  forms  in  early  preg- 
nancy, before  the  development  of  the  pla- 
centa; and  the  latter  if  the  mole  does  not 
develop  till  after  the  placenta.  In  the  first 
case  the  fetus  naturally  perishes;  in  the 
second,  it  may  come  to  maturity. 

Diagnosis. — This  can  be  made  to  a  cer- 
tainty only  by  palpating  the  cysts.  They 
may  be  felt  during  hemorrhage  when  the 
cervix  dilates  somewhat.  There  is  no  reason 
to  doubt  the  invariable  association  of  this 
disease  with  pregnancy.  Mistakes  have 
sometimes  been  made  by  confusing  true  hy- 
datid cysts  which  have  been  discharged  from 
the  uterus,  with  the  little  bladder-like 
growths  of  the  mole.  Hewitt  has  reported 
a  case  in  which  hydatids,  which  were  origin- 
ally in  the  liver,  had  extended  to  the  peri- 
toneum, and  were  just  at  the  point  of  burst- 
ing through  the  vagina  at  the  time  of  the 
patient's  death.  It  must  also  be  remem- 
bered that  hydatids  may  be  retained  in  the 

uterus  for  a  long  time,  and  then  be  discharged;  or  a  few  are  left  behind  that 
may  give  rise  to  a  new  set  of  growths,  and  these  be  extruded  long  after  im- 
pregnation. When  true  hydatids  obscure  the  diagnosis,  it  can  always  be  cleared 
up  by  microscopic  revelation  of  the  characteristic  heads  and  hooklets  of  the 
echinococcus. 

Etiology. — The  essential  cause  is  not  yet  determined.  Marchand  thinks 
it  most  probable  that  the  condition  is  due  primarily  to  a  change  in  the  ovum, 
an  argument  being  the  coexistence  of  a  normal  ovum  and  a  mole.  In  cases  of 
twins,  one  may  be  perfectly  healthy,  while  the  other  is  affected  (Fig.  238).  Some 
ascribe  the  cause  to  disease  of  the  mother;  the  arguments  for  this  theory  being 
the  occurrence  of  a  mole  several  times  in  the  same  woman,  and  its  frequent 
association  with  uterine  fibroids,  cancer,  or  syphilis.  Virchow  believed  it  to  be 
due  to  endometritis.  As  already  stated,  it  seems  most  prone  to  affect  older 
women.     Other  causes   assigned    are  pre-existing  metritis,  chronic  deciduitis. 


Fig.  238. — Cystic  Chorion  in  Twin 
Pregnancy.  Hemorrhage  During 
Labor. — (Bensinger.) 


200 


PATHOLOGICAL  PREGNANCY. 


uterine  fibroids,  maternal  syphilis  or  carcinoma,  absence  or  deficiency  of 
allantoic  vessels,  fetal  syphilis  or  other  disease,  fetal  death  (Gierse,  and  Grailly 
Hewitt). 

Symptoms  and  Clinical  History. — At  first  there  is  nothing  to  call  attention  to 
the  existing  disease,  and  it  is  only  with  the  advancement  of  pregnancy  that  the 
characteristic  symptoms  appear.  Three  symptoms  are  most  characteristic  of 
this  peculiar  disease:  (i)  The  uterus  enlarges  far  more  rapidly  than  in  preg- 
nancy. (2)  Hemorrhage  occurs,  small  in  amount,  or  diffuse,  irregular,  varying 
in  duration  from  several  hours  to  as  many  weeks.  These  hemorrhages  become 
more  severe  as  the  vesicles  grow  into  the  decidua,  and  consist  of  watery  and 
sanguineous  discharges,  which  have  been  hkened  to  currant-juice  in  appearance. 


Fig.  239. — Cystic  Chorion 
Perforating  the  Walls 
OF     Uterus.  —  (Spiegel- 
•) 


Fig.    240. — Cystic    Disease  of   the   Chorion.     Hydatidi- 
FOR.M   Mole. — {Photograph  of  the  author's  specimen.) 


They  are  probably  caused  by  the  breaking-down  of  the  cysts,  which  result  from 
painless  uterine  contractions.  The  great  increase  in  size  of  the  uterus  is  not 
apparent  till  the  third  or  fourth  month.  (3)  There  is  a  cystic  or  doughy  feel 
on  palpation,  while  the  outlines  of  the  fetal  tumor  are  very  obscure,  and  no 
fetal  heart  sounds  can  be  heard.  The  hemorrhages  may  be  frequent  and  profuse, 
or  one  attack  may  prove  quickly  fatal.  When  the  cysts  are  found  in  the  vaginal 
discharge  the  diagnosis  is  certain.  They  are  whitish,  sago-like  bodies,  generally 
surrounded  by  small  blood-clots.  There  are  numerous  reflex  symptoms  result- 
ing from  the  enlarged  abdomen;  viz.,  excessive  nausea,  vomiting,  faintness,  even 
syncope,  and  abdominal,  lumbar,  or  sacral  pains.  Extreme  exhaustion  may 
develop.  The  abdominal  pains  may  possibly  be  caused  by  the  growth  of  the 
vesicle  into    the  uterine  substance  (Fig.   239).     Renal  insufficiency  and   albu- 


DISEASES  OF  THE  CHORION.  201 

minuria  are  not  uncommon.  When  the  cystic  change  extends  to  involve  the 
uterine  wall,  the  disease  assumes  a  semi-malignant  character,  and,  septic  peri- 
tonitis and  death  may  result  from  perforation  of  the  uterus.  The  lower  third 
of  the  uterus  is  tense.     Ballotte'ment  is  obscure. 

Prognosis. — The  patient  rarely  goes  to  term,  and  the  fetus"  is  generally 
destroyed,  often  completely  absorbed.  The  maternal  mortality  is  13  per  cent. 
The  causes  of  maternal  death  are  hemorrhage,  septic  infection,  and  uterine 
perforation  with  peritonitis.  Generally  the  fourth  or  fifth  month  of  pregnancy 
sees  the  expulsion  of  the  ovum,  which  is  favored  by  the  unusual  growth  and 
consequent  overdistention  of  the  uterus,  as  well  as  by  the  irritation  caused 
by  the  penetration  of  the  uterine  substance.  Rarely,  a  group  of  cysts  may 
be  extruded  without  interrupting  the  course  of  pregnancy.  Cancer  of  the  uterus 
may  result.      (See  Chorio-epithelioma  Malignum.) 

Treatment. — After  the  condition  is  discovered  the  uterus  should  be  emptied 
in  order  to  prevent  infiltration  of  the  uterine  wall  by  the  syncytium.  The 
cervix  may  be  dilated  if  necessary  by  any  of  the  approved  methods  and  the 
growth  removed  by  the  fingers  or  curette.  The  latter  should  be  carefully  used 
on  account  of  the  danger  of  uterine  perforation.  After  evacuation  of  the 
uterine  contents,  the  woman  should  be  treated  as  a  puerperal  patient.  Full 
doses  of  ergot  should  be  given  for  some  days  after  the  removal  of  the  mole. 

2.  Fibre  myxomatous  Degeneration  of  the  Chorion,  or  Myxoma  Fibrosum. — • 
This  disease  is  even  more  rare  than  the  preceding.  It  is  limited,  as  a  rule,  to 
the  placental  area,  and  occurs  during  the  latter  part  of  pregnancy.  It  has 
been  described  by  Virchow  and  Hildebrandt,  and  is  characterized  by  fibroid 
degeneration  of  the  connective  tissue  of  the  chorion  at  the  placental  site.  Small 
tumors  are  formed  that  eventually  undergo  myxomatous  degeneration.  After 
this  change  has  taken  place  the  parts  concerned  have '  a  soft,  gelatinous  feel. 
The  fetus  may  not  be  destroyed,  on  account  of  the  tardy  development  of  the 
disease.  The  symptomatology  is  not  clear,  and  labor  may  take  place  before 
the  diagnosis  is  made.     The  treatment  can  only  be  symptomatic. 

3.  Chronic  Choriitis,  or  Inflammation  of  the  Chorion. — The  chorion  shares 
the  characteristics  of  other  vascular  tissues,  in  being  subject  to  low  grades  of 
inflammation.  From  this  cause  dense  adhesions  are  formed  between  the 
chorion  and  the  amnion  and  the  decidua.  Syphilis  may  often  account  for  this 
condition.  Or,  an  endometritis  may  be  the  forerunner  of  inflammation  of  the 
decidua,  in  which  the  chorion  takes  part.  Abortion  will  probably  result.  The 
treatment  is  symptomatic. 


III.  ANOMALIES  OF  THE  AMNION  AND   LIQUOR  AMNII. 

I.  Plastic  Exudation,  Amniotitis.  2.  Abnormal  Tenuity,  j.  Cysts  and  Dermoids.  4. 
Prem^ature  Rupture,  Amniotic  Hydrorrhea.  5.  Anomalies  in  Color  and  Composition  of 
Liquor  Amnii.     6.  Oligohydramnios.     7.  Hydranmios. 

Introduction. — As  might  logically  be  expected,  the  similarity  between  the 
pathology  of  this  fetal  membrane  and  that  of  other  serous  structures  is 
very  striking.  There  is  the  same  chance  for  the  occurrence  of  changes  of  secre- 
tion, inflammations,  exudations,  serous  and  plastic,  and  bands  of  adhesions. 

I.  Plastic  Exudation,  Amniotitis  or  Amnitis. — This  affection  generally  occurs 
in  embryonal  life,  when  the  amnion  lies  against  the  developing  skin  of  the 
child,  and  it  is   due   to  the  scarcity  of  liquid,  and  its  failure,'  consequently. 


202 


PATHOLOGICAL  PREGNANCY. 


to  lift  the  fetal  membrane  from  the  child's  body.     When  this  condition  is  exten- 
sive, two  results  may  follow:  First,  the  decidua  becomes  detached,  and  this  is 
naturally  followed  by  death  of  the  fetus 
and  severe  hemorrhage  from  the  ma-  i 

ternal  vessels.     Second,  a  great  many 
fetal    malformations    may    occur,    for 


Fig.  241. — An  Amniotic  Adhesion  Ex- 
tending FROM  THE  Scalp  to  the  Edge 
OP  THE  Placenta,  and  Twisted  Around 
THE  Umbilical  Cord.  The  Fetus  Has 
A  Double  Hare-lip. — (Winckel.) 


Fig.  242.  —  Normal  and  Pathological 
Amnion  Epithelia.  I,  Normal  amnion 
epithelia;  II,  amnion  epithelia  in  hy- 
dramnios;  III,  the  same  with  giant  cell. 
—{Ahlfeld.) 


bands  of  plastic  exudation  are  formed,  which  connect  the  fetus  and  amnion. 
As  the  amniotic  cavity  grows,  these  bands  are  stretched,  and  they  m^ay  connect 

different  parts  of  the 
fetus ,  or  one  or  both  ends- 
may  freely  float  in  the 
surrounding  liquid. 
There  are  no  blood- 
vessels in  these  bands. 
At  times  they  prevent 
the  normal  arching  over 
of  the  body-cavities,  and 
eventration,  anenceph- 
alus,  or  some  other  ano- 
maly of  non-union  re- 
sults. Spontaneous  or 
intrauterine  amputa- 
tions not  infrequently 
follow  amniotitis ;  the 
bands  may  wrap  around 
a  limb,  and  so  constrict  its  blood-supply  that  its  further  development  is  impossi- 
ble; and  there  is  either  perfect  separation,  or  the  part,  hindered  in  its  growth^ 


Fig.   243. — -Amputation  of  Arm  by  Amniotic  Adhesions. 


ANOMALIES  OF  THE  AMNION  AND  LIQUOR  AM  Nil. 


2oa 


atrophies.  If  the  Hmb  is  completely  amputated,  and  this  has  happened  before 
the  third  month  of  pregnancy,  there  will  probably  be  entire  absorption  of  the 
member  before  birth.  If  later  than  this  period,  the  amputated  part  may  be 
extruded  in  labor  after  the  birth  of  the  child.  The  idea  that  the  umbilical  cord 
produces  amputations  is  erroneous,  for  the  cord  itself  would  be  so  compressed 
in  such  a  case  that  its  circulation  would  be  interfered  with,  and  the  child 
would  die  of  asphyxia. 

2.  Abnormal  Tenuity. — In  the  latter  part  of  gestation,  on  account  of  abnormal 

tenuity  or  thinness,  the  amnion  may 
rupture  and  become  separated  from 
the  chorion.  The  latter  remains  in- 
tact, while  the  amnion  is  rolled  on  it- 
self, forming  cords  or  bands,  which 
may  wind  around  the  fetus,  or  be- 
come so  entangled  with  the  umbilical 
cord  as,  by  constriction,  to  cut  off  its 
blood-supply,  thus  causing  the  death 
of  the  fetus. 

3.  Cysts,  Dermoids. — The  forma- 
tion of  cysts  in  the  substance  of  the 
amnion  has  been  described;  they  are 


Fig.  244. — Deformities  of  the  Face  and 
Skull  Caused  by  Amniotic  Adhesions. 
—{Lepage.) 


Fig.  245. — Dermoids  of  the  Amnion.  I, 
Multiple  dermoids  (i) ;  II,  one  of  the  der- 
moids with  daughter-cyst. — (Ahlfeld.) 


small  and  of  no  clinical  importance.  Dermoids  have  also  been  described.  One 
has  been  observed  that  was  attached  by  a  pedicle  to  the  amnion  of  an  aborted 
fetus.  Besides  cysts,  caruncles  and  tuft-like  growths  have  been  noted  in  con- 
nection with  the  amnion.  In  the  case  of  fetal  death,  certain  changes  take  place 
in  the  amnion,  which  result  in  the  loss  of  its  glistening  appearance,  and  in  a  con- 
siderable thickening  of  its  substance.  The  histology  of  this  condition  is  not 
understood  (Fig.  245). 

4.  Amniotic  Hydrorrhea. — Rupture  of  the  amnion  may  be  followed  by  abor- 
tion.    Occasionally,  however,  the  amnion  and  chorion  are  ruptured  at  a  point 


204 


PATHOLOGICAL  PREGNANCY. 


remote  from  the  internal  os,  and  the  amniotic  Hquid  drips  away  for  weeks  before 
labor.     This  is  called  amniotic  hydrorrhea  (Fig.  247). 

5.  Anomalies  in  Color  and  Composition  of  the  Liquor  Amnii. — The  color, 
which  in  the  latter  part  of  gestation  is  normally  an  opaque  white,  may  become 
reddish  from  the  presence  of  a  macerated  fetus,  or  it  may  be  green  or  brown, 
from  the  escape  of  fetal  meconium.  When  the  amount  of  liquid  is  extremely 
small,  its  consistency  may  resemble  that  of  molasses  or  mucus.  If  the  mother 
has  diabetes  mellitus,  it  may  contain  sugar.  Sometimes  the  liquor  amnii  is 
decomposed.  This  is  generally  coincident  with  the  death  and  putrefaction 
of  the  fetus,  in  which  case  a  true  physometra  (gaseous  products  of  putrefaction) 
is  present  to  a  certain  degree.  However,  instances  in  which,  with  this  condi- 
tion, the  fetus  was  born  alive  are  on 

record.     For  such  cases  no  explana- 
tion has  yet  been  given. 

6.  Oligohydramnios  consists  of  a 
deficiency  of  the  amniotic  liquid. 
This  is  a  rather  rare  condition,  oc- 


\ 


Fig.  246. — Compression  of  the  Fetus 
IN  Oligohydramnios. — (Ahlfeld.) 


Fig.  247. — Diagrammatic  Representation 
OF  THE  Different  Varieties  of  "False" 
Amniotic  Cavities  and  Waters,  a,  Am- 
nio-chorionic water;  d,  decidual  water;  t, 
true  amniotic  cavity  and  liquor  amnii 
proper. — (Bumm.) 


curring  only  once  in  three  or  four 
thousand  cases.  The  great  disad- 
vantages of  this  affection  are  seen  in 

the  early  part  of  pregnancy;  for  the  uterine  walls  are  not  sufficiently  separated, 
and  consequently  fetal  deformities  occur,  such  as  talipes,  bowing  of  the  limbs, 
ulcers  on  the  prominent  parts  of  the  body  from  the  constant  friction,  adhesions 
between  the  amnion  and  fetal  surfaces,  and  intrauterine  amputations.  In  some 
cases  abortion  occurs,  as  the  growth  of  the  fetus  is  seriously  interfered  with. 
When  this  condition  continues  into  advanced  pregnancy,  the  uterus  is  strikingly 
small  and  hard.  The  movements  of  the  fetus  being  limited,  the  mother  becomes 
so  conscious  of  them  as  actually  to  suffer  discomfort  or  pain  therefrom.  Labor 
is  generally  difficult  and  abnormally  prolonged.  No  treatment  is  available, 
even  though  the  condition  is  diagnosticated  before  birth. 

7.  Hydramnios,  Polyhydramnios,  Hydrops  Amnii,  or  Dropsy  of  the  Amnion. — 
Definition. — This  condition  consists  in  the  excessive  accumulation  of  amniotic 
fluid  in  the  amnion,  or  of  a  deficient  absorption  of  the  same. 


ANOMALIES   OF   THE  AMNION  AND  LIQUOR   AMNII.  205 

Pathology. — It  is  difficult  to  estimate  exactly  the  normal  amount  of  liquor 
amnii,  for  in  labor  it  dribbles  away  and  is  mixed  with  blood;  but  approximately 
it  measures  from  one  to  two  pints.  If  there  is  much  more  than  this  quantity, 
hydramnios  exists.  The  condition  is  not  pathological  until  about  five  pints 
accumulate.  In  general,  the  liquid  collects  gradually  but  persistently,  giving 
a  chronic  form  to  the  affection,  till  at  term  it  may  reach  six  gallons  and  more. 
There  is  a  condition  known  as  actite  hydramnios,  in  which  the  increase  is  very 
rapid,  and  from  the  resulting  distention  of  the  uterus  grave  symptoms  super- 
vene. It  may  develop  within  a  few  days,  or,  as  in  a  case  reported  by  Sentex, 
in  a  single  night.  This  affection  usually  occurs  in  early  pregnancy,  and  at  the 
fifth  or  sixth  month  the  abdomen  is  as  large  as  it  would  normally  be  at  the 
ninth  or  tenth  month,  or  even  larger.  Schneider  observed  thirty  liters  at  six 
months.  The  character  of  the  liquid  is  generally  like  that  of  the  normal  liquor 
amnii.  Prochownik  states  that  it  contains  more  urea  than  is  normally  present, 
owing  to  excessive  secretion  of  the  fetal  kidneys.  This  condition  is  frequently 
associated  with  monsters;  hydrocephalus,  hemicephalus,  spina  bifida,  cleft  palate, 
harelip,  club-foot,  or  some  other  deformity  is  present  in  lo  per  cent,  of  cases. 

Frequency. — Hydramnios  occurs  once  in  250  or  300  cases.  It  is  more  frequent 
in  multigravidae  than  in  primigravidas  (23  to  5);  more  frequent  in  twin  preg- 
nancies of  the  same  sex  than  in  single  pregnancies.  There  are  some  cases  of 
twins  in  which  one  sac  contains  more  liquid  than  normal,  while  the  other  contains 
less.     This  condition  has  been  observed  in  extrauterine  pregnancy. 

Etiology. — Three  general  causes  are  accepted  in  the  etiology  of  this  affection: 
(i)  Fetal,  (2)  maternal,  (3)  amniotic.  In  abnormal  states,  in  which  the  liquor 
amnii  comes  in  contact  with  the  floor  of  the  fourth  ventricle,  fetal  diabetes 
mellitus  is  caused,  and,  in  consequence,  an  excess  of  fetal  urine  in  the  amniotic 
fluid.  Changes  or  obstructions  in  the  umbilical  vein,  such  as  phlebitis  and 
thrombosis,  also  torsion  of  the  cord,  will  cause  damming  back  of  the  blood, 
and  resulting  transudation  of  serum.  A  large  fetal  bladder,  by  pressure  on 
the  vein,  will  force  the  blood  back  into  the  placenta.  Lesions  of  the  liver, 
the  heart,  the  blood-vessels,  or  the  kidneys  of  the  mother,  by  interfering  with 
circulation,  may  cause  this  trouble.  Albuminuria,  diabetes,  and  syphilis  have 
been  claimed  as  sources  of  the  affection,  as  well  as  leukemia  and  anemia.  The 
amount  and  degree  of  transudation  through  the  amnion  has  been  proved  by 
Sallinger  to  depend  upon  the  strength  of  the  blood-pressure  in  the  umbilical 
vein,  and  upon  the  size  of  the  cord.  Tumors  of  the  placenta,  causing  an  increased 
blood-pressure,  will  cause  transudation,  as  will  also  fetal  tumors  that  obstruct 
the  circulation.  The  fetal  skin  may  be  the  source  of  hydramnios.  An  abnor- 
mal blood-supply,  sent  by  a  hypertrophied  heart,  may  excite  the  skin  to 
extra  activity.  Other  cases  of  extensive  nsevi,  thickened  skin,  and  elephan- 
tiasis congenita  cystica,  have  been  reported  in  association  with  hydramnios. 
The  amnion  itself  may  be  productive  of  hydramnios.  The  condition  of  acute 
inflammation,  amniotitis,  may  be  followed  by  extreme  serous  exudation.  This 
etiological  factor  would  explain  cases  of  hydramnios  which  follow  traumatism 
of  the  abdomen  of  a  pregnant  woman.  Adhesions  between  amnion  and  fetus 
have  been  developed  in  such  cases.  Acute  hydramnios  has  also  been  ascribed 
to  this  cause.  McClintock  reports-  that  in  about  75  per  cent,  of  the  cases  he 
has  studied  the  fetus  has  been  of  the  female  sex.  Hydramnios  is  at  times  ob- 
served in  association  with  serous  effusions  in  other  parts  of  the  maternal  organ- 
ism. It  would  therefore  be  of  value  in  this  trouble  to  make  a  blood  examina- 
tion of  the  mother,  in  order  to  ascertain  if  the  hydremia  so  commonly  found 
in   pregnane}^   is   increased.     Certain   cases   of    dropsy   of    mother  and    child. 


206  PATHOLOGICAL  PREGNANCY. 

associated  with  this  affection  and  syphiHtic  in  origin,  have  been  reported.  As 
to  the  theory  of  deficient  absorption  of  liquor  amnii,  those  cases  of  hydramnios 
coincident  with  nephritis  and  serous  effusions  in  the  mother  could  be  explained 
in  this  way.  In  this  affection  the  fetus  is  often  born  dead  and  shriveled,  and 
the  placenta  is  enlarged  and  oedematous.  Maternal  mortality  after  labor  is  also 
high,  probably  dependent  upon  the  debilitated  state  of  the  patients.  The  large 
majority  of  cases  which  admit  of  any  explanation — for,  according  to  Bar,  44  per 
cent,  of  all  cases  have  no  demonstrable  cause — can  be  traced  to  a  fetal  origin. 

Symptoms. — In  the  acute  form  the  symptoms  are  sudden,  often  intense, 
pain;  fever,  from  the  acute  inflammation  of  the  amnion;  a  great  and  rapid 
abdominal  distention;  inability  of  the  patient  to  lie  down;  irregularity  of  pulse 
and  respiration;  dyspnea;  and  lividity  of  the  face.  The  symptoms  may  be 
slight  or  pronounced.  In  the.  chronic  form,  the  undue  pressure  of  the  uterus 
on  the  abdominal  contents  causes  impeded  respiration  and  palpitation  of  the 
heart  from  the  upward  displacement  of  the  diaphragm.  But  in  this  form 
the  accumulation  of  the  liquid  is  gradual,  and  is  consequently  not  followed 
by  the  severe  symptoms  of  the  acute  form.  The  distention  becomes  notice- 
able about  the  third  or  fourth  month.  It  gradually  and  slowly  increases, 
causing  little  discomfort  to  the  mother.  The  patient  is  often  somewhat  de- 
pressed, but  suffers  little  disturbance  in  general  health.  Sometimes  insomnia 
is  present,  caused  by  the  sensation  of  weight  in  the  pelvis,  which  does  not 
amount  to  real  pain.  Neuralgia  of  the  abdominal  walls,  pelvis,  and  lower 
extremities  results  from  pressure  on  the  pelvic  and  sacral  plexuses ;  and  oedema 
of  the  abdomen,  genitalia,  and  limbs,  from  obstructed  pelvic  circulation.  There 
are  excretion  of  scanty  and  albuminous  urine,  from  interference  with  the  renal 
circulation;  digestive  disturbances,  as  a  reflex  result  of  great  uterine  distention, 
or  from  the  direct  pressure  on  the  abdominal  viscera,  and  at  times  ascites, 
caused  by  pressure  upon  the  portal  vein.  As  a  rule,  the  symptoms  of  preg- 
nancy are  increased  in  severity.  The  abnormally  rapid  increase  in  size  of  the 
uterus  is  the  most  striking  symptom  of  this  condition.  Relief  is  often  afforded 
by  the  occurrence  of  premature  labor,  the  first  stage  generally  being  tedious, 
from  the  overdistention  of  the  uterus.  From  this  same  cause  there  is  a  greater 
tendency  than  normal  to  post-partum  hemorrhage,  just  as  in  the  case  of  twins. 

Physical  Signs. — On  inspection,  we  find  abnormal  distention  of  the  abdo- 
men. Palpation  shows  an  enormous  uterus,  with  tense  and  rather  elastic 
parietes,  and  vague  fluctuation.  The  fetus  may  easily  be  moved  from  one 
point  to  another,  or  even  inverted.  Auscultation  reveals  either  a  total  absence 
of  fetal  heart  sounds,  or  a  mufffed  tone.  Vaginal  examination  will  show  the 
elevation  of  the  os,  with  a  partial  obliteration  of  the  cervical  canal.  The  lower 
uterine  segment  is  elastic  and  tense,  and  the  presenting  part  of  the  fetus  cannot 
readily  be  palpated. 

Diagnosis. — As  a  rule,  the  diagnosis  is  not  difficult.  If  there  exists  a  larger 
uterus  than  normal,  the  diagnosis  of  hydramnios  is  justifiable.  There  is,  too, 
the  history  of  pregnancy  to  add  its  weight  of  evidence.  However,  difficulties 
not  uncommonly  arise  when  there  is  a  large  collection  of  fluid,  and  when  the 
fetus  is  small,  or  dead,  so  that  there  is  an  absence  of  fetal  heart  sounds  and 
movexnents.  It  often  occurs  that,  even  though  the  enlarged  uterus  will  give 
a  liquid  wave  as  distinct  as  that  felt  in  an  ovarian  cyst,  still  by  dipping  deeply 
on  palpation,  the  solid  body  of  the  fetus  can  be  detected.  The  fetus  will  be 
abnormally  movable.  Differential  diagnosis  between  hydramnios  and  ovarian 
cyst  may  be  made  by  observing  the  following  point:  the  development  of  hy- 
dramnios is  far  more  rapid.     If  there  exist  (i)  the  fetal  heart  sounds,  (2)  if 


ANOMALIES  OF  THE  AMNION  AND  LIQUOR  AMNIL         207 

the  fetal  body  can  be  mapped  out,  (3)  if  the  hypertrophied  round  Hgaments 
can  be  traced,  ovarian  cyst  can  be  excluded.  The  normal  position  of  the 
uterus,  whether  pregnant  or  riot,' is  low  down  in  the  pelvis  in  ovarian  dropsy, 
while  in  hydramnios  it  is  drawn  high  up,  and  felt  per  vaginam  with  difficulty 
(Kidd).  The  facies  of  ovarian  trouble  is  characteristic  in  advanced  cases. 
Finally,  emaciation  occurs.  A  most  valuable  distinction  is  the  presence  of 
Braxton-Hicks's  sign,  which  always  exists  in  pregnancy, — the  occasional  rhyth- 
mic contractions  of  the  uterus,  especially  when  excited  by  manipulation.  If 
it  can  be  proved  that  the  hardening  of  the  uterine  wall  thus  produced  extends 
over  the  whole  surface  of  the  tumor,  then  it  is  positive  that  the  whole  mass 
is  uterus.  When  from  its  great  distention  the  uterus  resembles  a  large  ovarian 
cyst,  the  cervix  will  generally  yield  more  than  it  normally  does  at  the  fifth 
or  sixth  month  of  pregnancy,  so  much  so  that  the  finger  can  be  inserted  within 
it  till  it  reaches  the  membranes.  Hydramnios  may  be  confused  with  preg- 
nancy complicated  with  ascites,  though  it  may  be  distinguished,  before  it  has 
proceeded  too  far,  by  mapping  out  the  uterine  parietes,  and  by  the  detection 
of  resonance  along  the  flanks,  in  the  dorsal  decubitus;  or  with  a  cystic  tumor 
of  the  broad  ligament,  or  with  a  normal  twin  pregnancy.  This  diagnosis  may 
be  difficult  or  even  impossible,  but  usually  in  hydramnios  the  uterine  enlarge- 
ment is  more  tense  or  fluctuating.  The  fetal  membranes  may  be  palpated, 
and  the  lower  uterine  segrnent,  felt  by  vaginal  examination,  is  generally  dis- 
tended, and  the  presenting  part  not  palpable.  This  condition  has  been  mis- 
taken for  distended  bladder,  with  retroversion  of  the  uterus.  When  the  uterus 
is  extended  to  its  extreme  limit,  and  a  certain  diagnosis  cannot  be  made,  the 
advisability  of  an  abdominal  exploratory  operation  should  suggest  itself,  since 
but  slight  danger  attends  such  a  procedure.  Abdominal  ascites  pure  and  simple 
must  also  be  distinguished  by  the  superficial  position  of  the  fluid,  the  difficulty 
of  mapping  out  the  uterus,  and  the  physical  signs,  which  show  that  the  fluid 
exists  free  in  the  peritoneal  cavity,  and  by  the  presence  of  dropsical  effusions 
in  other  parts  of  the  body.  The  area  of  dulness  is  variable,  depending  upon 
change  of  position  of  the  patient.  There  is  decrease  in  the  quantity  of  urine 
and  it  is  whitish  and  turbid.  Extreme  and  constant  thirst  is  present.  There 
is  a  great  distention  of  the  hypochondria.  In  an  extreme  degree  of  ascites 
there  is  marked  protuberance  of  the  umbilicus. 

Prognosis. — Authorities  differ  as  to  the  gravity  of  the  prognosis.  It  cer- 
tainly is  not  very  good  for  the  mother,  though  naturally  it  depends  on  the 
cause  of  the  existing  condition.  McClintock,  out  of  thirty-three  patients  with 
hydramnios,  lost  four  by  rupture  of  the  uterus,  two  by  exhaustion,  and  one 
by  infection.  Winckel  lost  one  by  pre-existing  pneumonia,  while  another  had 
an  attack  of  paracolpitis  and  parametritis,  although  she  recovered.  The  preg- 
nancy has  a  decided  tendency  to  terminate  early,  from  the  extreme  uterine 
distention,  from  the  death  of  the  fetus,  or  from  the  untimel}'-  detachment  of  the 
placenta;  thus  subjecting  the  patient  to  the  risks  of  premature  labor.  Post- 
partum hemorrhage  is  very  apt  to  occur  on  account  of  the  uterine  inertia, 
caused  by  extreme  distention,  and  consequent  weak  labor  pains  and  protrac- 
tion of  labor.  Involution  is  prolonged,  or  not  fully  completed.  Death  may 
be  a  sequela,  due  to  exhaustion,  particularly  in  the  acute  variety.  Fetal  prog- 
nosis is  unquestionably  bad.  Fully  25  per  cent,  of  the  children  die.  This 
high  degree  of  mortality  follows  from  fetal  malformations,  dropsical  troubles, 
prematurity,  and  the  frequency  of  abnormal  presentations.  Charpentier  col- 
lected 113  cases,' in  which  20  presented  by  the  shoulder,  21  by  the  breech,  and 
2  by  the  face.     Many  fetuses  are  in  a  diseased  condition,  and  after  birth  show  a 


208  PATHOLOGICAL   PREGNANCY. 

variety  of  pathological  coajditions :  viz.,  syphilis,  hydrocephalus,  or  elephantiasis. 
The  common  occurrence  of  prolapsed  cord  also  adds  to  the  fetal  mortality. 

Treatment. — The  treatment  should  generally  be  expectant.  The  acute 
cases,  however,  demand  immediate  evacuation  of  the  contents  of  the  uterus. 
The  OS  should  be  dilated  and  the  membranes  then  punctured.  The  method 
of  aspiration  of  the  fluid  through  the  walls  of  the  uterus  should  not  be  counte- 
nanced. The  precipitate  discharge  of  the  fluid  should  be  avoided ;  the  hand  or 
gauze  may  be  used  as  a  plug.  Serious  cardiac  disturbances  on  the  part  of  the 
mother,  or  extreme  discomfort,  should  indicate  premature  delivery.  Especially 
if  there  is  danger  of  death  of  mother,  labor  should  be  immediately  induced.  It 
has  been  suggested  that  a  minute  aspirating  needle  be  inserted  through  the  os, 
and  a  part  of  the  amniotic  liquid  thus  removed,  in  order  to  relieve  the  distressing 
symptoms,  but  not  to  bring  on  labor.  This  should,  of  course,  be  delayed  as 
long  as  is  consistent  with  the  safety  of  the  mother,  although  the  great  possibility 
of  a  monstrosity,  or  at  least  of  a  poorly  developed  child,  diminishes  the  danger 
of  prematurely  induced  labor.  In  such  cases,  measures  to  prevent  hemorrhage 
should  be  instituted.    The  malposition  of  the  fetus  should  also  be  guarded  against. 

Chronic  hydramnios  should  be  treated  by  the  application  of-  an  abdominal 
binder  (Fig.  228)  and  enforced  rest  on  the  part  of  the  mother,  in  order  to  give 
the  fetus  the  best  opportunity  to  survive.  In  mild  cases,  interference  is 
not  necessary;  but  if  severe  respiratory  or  cardiac  symptoms,  great  exhaustion, 
etc.,  are  present,  the  pregnancy  should  be  terminated,  as  in  the  acute  form. 
The  liquor  amnii  should  be  allowed  to  escape  slowly,  in  order  to  avoid  syncope, 
prolapse  of  the  cord,  and  hemorrhage  from  premature  detachment  of  the  pla- 
centa. The  precautions  against  hemorrhage  should  be  observed,  and  every 
endeavor  made  to  secure  firm  uterine  contractions.  If  the  expulsion  of  the 
fetus  is  too  slow,  it  must  be  assisted  in  some  way;  although  too  early  appli- 
cation of  the  forceps  should  be  avoided,  for  fear  of  the  later  hemorrhage.  After 
delivery  by  whatever  method,  there  should  be  careful  observation  of  the  uterus 
for  some  time,  and  besides  giving  ergot,  we  should  stimulate  its  contractions 
by  the  firm  grasping  of  the  uterus  and  by  hot  injections. 


IV.  ANOMALIES  AND  DISEASES  OF  THE  PLACENTA. 

I.  Anomalies. — (7)  Size:  (a)  Atrophy,  (b)  Hypertrophy,  (c)  Placenta  Memhranacea;  (2) 
Form;  (j)  Num.ber;  (4)  Relation;  (5)  Insertion — Placenta  Prcsvia.  2.  Injuries. — Prema- 
ture Detachment;  Accidental  Hemorrhage,  j.  Stasis  and  CEdema.  4.  Interstitial  Hemor- 
rhage— Apoplexy;  Infarction;  Thrombosis.  5.  Placentitis. — (/)  Acute  Septic,  (2)  Gonorrheal, 
(_j)  Emanuel's  Disease,  (4)  Specific,  (5)  Chronic  Interstitial  and  (6)  Albutninuric.  6.  In- 
fectious GranuLomata.  Tuberculous  and  Syphilitic.  7.  Secondary  Metamorphosis. — (i)  Pro- 
gressive Hyperplastic  and  Sclerotic,  Adherent  Placenta;  (2)  Regressive,  Results  of  Fetal 
Death;  White  Infarcts;  Cystic,  Calcareous,  Fatty,  and  Miscellaneous  Degenerations. 
8.  Tumors. — Placentomata,  Polypi. 

General  Remarks. — -A  perfectly  satisfactory  account  of  affections  of  the  placenta  cannot 
be  written  because  of  our  ignorance  of  the  histology  and  development  of  this  organ.  No 
distinction  can  be  made  between  the  fetal  and  maternal  placenta  from  the  standpoint  of 
pathology,  because  affections  appear  in  both  simultaneously,  or  pass  from  one  to  the  other. 

Etiology. — Diseases  of  the  placenta  originate  as  follows:  (i)  From  certain  pathological 
conditions  in  the  maternal  organism,  and  especially  endometritis  which  antedates  concep- 
tion. (2)  From  general  diseases  affecting  the  mother,  as  syphilis,  tuberculosis,  acute  infec- 
tious diseases,  nephritis,  leukemia,  exophthalmic  goitre.  In  this  class,  too,  lesion  of  the 
endometrium  is  the  connecting-link  between  the  maternal  and  placental  diseases.  The 
endometritis,  however,  does  not  necessarily  antedate  conception,  but  may  develop  during 
pregnancy,  the  fetal  portion  of  the  placenta  being  the  first  to  suffer.  (3)  From  primary 
disease  of  the  fetus,  especially  disturbances  of  the  circulation  including  the  umbilical  vessels. 


ANOMALIES  AND   DISEASES   OF   THE   PLACENTA.  209 

When  the  fetus  dies  from  whatever  cause,  certain  alterations  are  regularly  produced  in  the 
placenta,  such  as  obliteration  of  the  vessels  and  fibrous  degeneration  of  the  cells.  The  con- 
verse, of  course,  is  true,  so  that  disease  of  the  fetal  and  maternal  placenta  may  cause  defective 
nourishment  and  development  of  the  fetus  as  well  as  the  death  of  the  latter,  not  only  during 
pregnancy  but  in  the  course  of  an. otherwise  normal  labor.  This  termination  of  pregnancy 
may  occur  repeatedly  in  the  same  woman.  If  the  fetus  with  a  diseased  placenta  survives, 
the  increased  resistance  encountered  by  the  placental  circulation  may  have  produced  disease 
of  the  heart  or  of  some  of  the  other  viscera.  Again,  the  fetus  may  not  die  in  utero  as  a  result  of 
the  placental  disease,  but  the  pregnancy  may  terminate  in  missed  labor,  premature  labor, 
or  premature  separation  of  the  normally  situated  placenta.  Placental  disease  is  also  respon- 
sible for  some  cases  of  hydramnios.  We  are  unable  to  state  whether  placental  affections 
can  affect  the  health  of  the  mother  (nephritis  of  pregnancy,  eclampsia,  etc.).  They  play  a 
very  prominent  role,  however,  in  connection  with  labor  (accidental  and  unavoidable 
hemorrhage,  adhesions,  retention,  etc.). 

Diagnosis. — There  are  no  known  methods  by  which  placental  diseases,  with  the  excep- 
tion of  placenta  prasvia  and  accidental  hemorrhage,  may  be  recognized  in  utero. 

Treatment. — With  the  exception  of  syphilis  of  the  placenta  we  know  of  no  affection  of 
the  latter  organ  which  can  be 'affected  by  treatment. 

I.  Anomalies. — (i)  Size. — (a)  Atrophy:  By  this  term  is  meant  simple 
qualitative  atrophy,  and  not  the  diminution  in  size  which  is  secondary  to  in- 
flammatory affections.  There  is  a  tolerably  definite  relationship  between  the 
fetal  and  placental  weights  under  normal  conditions  which  is  expressed  by 
5.5  :  I.  When  an  otherwise  normal  placenta  is  of  smaller  size  than  this  ratio 
requires,  a  condition  of  arrested  development  is  present.  Nothing  whatever 
is  known  of  the  causes  of  primary  atrophy,  which  is  seen  alike  in  the  ill-nourished 
and  the  robust.  (6)  Hypertrophy:  Simple  hypertrophy  is  the  opposite  to  the 
condition  just  described,  the  placenta  being  increased  in  area  and  thickness 
although  of  normal  quality.  It  should  not  be  confounded  with  an  oedematous 
or  hyperplastic  placenta.  As  this  condition  is  encountered  only  with  very  large 
fetuses,  and  preserves  the  habitual  ratio,  it  is  hardly  to  be  ranked  among  ano- 
malies, (c)  Placenta  Membranacea:  This  rare  anomaly  represents  a  placenta  which 
extends  over  the  greater  portion  or  even  the  whole  of  the  chorionic  surface 
(Figs.  256  and  269).  The  expanded  structure  is  correspondingly  thin  and  mem- 
branous in  texture.  In  this  anomaly  there  is  an  evident  failure  on  the  part  of 
the  decidua  serotina  to  develop  into  the  normal  placenta,  with  persistence  of 
the  chorionic  villi.  Clinically  this  anomaly  generally  constitutes  a  prsevia  (Fig. 
269),  and  also  complicates  the  third  stage  of  labor  by  retention  or  actual  adhesion 
and  resulting  hemorrhage.     Fortunately,  it  is  very  rarely  encountered  in  practice. 

(2)  Anomalies  of  Form. — These  are  best  considered  collectively.  The  prin- 
cipal aberrations  in  the  shape  of  the  placenta  are  as  follows:  (i)  Lobate  placenta, 
in  which  the  organ  is  divided  into  two  or  more  lobes  (Figs.  249,  250,  251,  254, 
and  255).  (2)  Horseshoe  placenta  (placenta  reniformis)  (Fig.  257).  (3)  Fenes- 
trated placenta,  characterized  by  one  or  more  solutions  of  continuity  in  the  sub- 
stance of  the  organ  through  which  the  chorion  is  visible  (Fig.  253).  Anmdar 
placenta,  which  extends  about  the  uterine  cavity  like  a  belt  (Fig.  253).  Von 
Franque  explains  these  anomalies  by  the  supposition  of  abnormal  development 
which  results  from  endometritis.  Some  of  the  chorionic  villi  failing  to  develop, 
the  placenta  exhibits  corresponding  defects  through  which  fantastic  forms  are 
assumed.  Clinically,  all  of  the  preceding  placentae  may  cause  disturbance  of  the 
third  stage  of  labor  through  partial  detachment  and  retention.  They  are  less  to 
be  feared  in  this  respect,  however,  than  the  subsequent  class. 

(3)  Anomalies  of  Number. — These  represent  apparently  a  higher  degree  of 
the  process  involved  in  the  genesis  of  the  preceding  class.  Generally  speaking, 
they  are  included  under  the  term  supernumerary  or  accessory  placentas.  If 
these  subsidiary  structures  contribute  to  the  nourishment  of  the  fetus,  they  are 
termed  placentcz  succenturiat(£ ;  otherwise  they  are  known  as  false  placentae  (pla- 

14 


Fig. 


. — Irregularly  Formed  Pla- 
centa.— (Auvard.) 


Fig.  249. — Placenta  with  Several 
Irregular  Lobes. — (Auvard.) 


Fig. 


250. — Placenta  with  Two  Equal 
Lobes. — (Ribemont-Lepage.) 


Fig.  251. — Placenta  with  Two  Un- 
equal Lobes. — (Auvard.) 


Fig.  252. — Placenta  Succen- 
turiata. — (Ribemont-Lepage.) 


Fig.  253. — Fenestrated  Twin  Placenta  at 
Seventh  Month. — (Hyrtl.) 


210 


«^tw  "^ 


iSt-^'' '  • 


Fig.    254. — Trilobed     Placenta, 
Two  Lobes  Equal  in  Size. 


Fig.  255. — Placenta  with  Two  Unequal 
Lobes  and  Velamentous  Cord  Insertion. 
— (Ribemont-Lepage.) 


Fig.  256. — Placenta  Membranacea. 
(Ahlfeld.) 


Fig.  257. — Bilobed  Placenta. 
"Horseshoe"   Placenta. 


~..^' 


Fig.  258. — Placenta  in  Triplets.  Three  Dis- 
tinct Masses  of  Placenta,  with  an  Isolated 
Cotyledon. — (Ribemont.) 


Fig.  259. — Small  Accessory 
Placenta.  —  (Ribemont-Le- 
page.) 


211 


212 


PATHOLOGICAL  PREGNANCY. 


centae  spuriae).     As  many  as  half  a  dozen  of  these  accessory  organs  have  been 
found  in  a  single  uterus. 

These  anomalies  probably  originate  in  one  of  two  ways:   (i)   Endometritic 


^\ 


Fig.  260. — Battledore  Oval  Placenta. 
{Auvard.) 


Fig.  261. — Placenta  with    Velamentgus 
Cord  Attachment. — (Ribemont-Lepage.) 


proliferation  during  the  developm.ent   of  the   placenta  may  divide  the  latter 
into    two    or    more    segments,    some   of    which    may    be    small — mere    single 

cotyledons,  in  fact.  (2)  An 
ovum  may  be  implanted 
over  a  uterine  angle,  where 
a  complete  placenta  would 
not  form;  as  a  result  pla- 
cental tissue  develops  on 
either  side  of  the  angle. 
This  particular  type  is 
known  as  the  duplex  or  bi- 
partite placenta.  Multiple 
placenta  as  a  class  are  said 
to  occur  in  one  labor  out  of 
about  352  (Ribemont-Des- 
saignes).  The  most  common 
type  of  multiple  placenta  is 
the  placenta  duplex,  or  bi- 
lobed  placenta,  which  was 
encountered  by  Ahlfeld  5 
times  in-  3000  cases  (Figs. 
249  to  251).  These  ano- 
malies may  cause  serious 
complications  of  the  third 
stage  of  labor.  The  practi- 
tioner should  always  ex- 
amine a  placenta  carefully 
to  make  sure  that  there  is  no 
apparent  loss  of  substance. 

(4)  Anomalies    of  Re- 
lation.— By    this    term    is 
meant  the  anomalous  rela- 
tions which   may  exist  between  the  placenta  and  the  other  fetal  appendages 
(membranes,  cord).     Battledore  Placenta:  This  term  is   applied  to  a  placenta  in 


Fig.  262. — Placenta  Succenturiata. — {Author's  case.) 


ANOMALIES  AND   DISEASES  OF   THE  PLACENTA. 


213 


which  the  cord  has  a  lateral  implantation  (Fig.  260).  It  is  considered  under 
Anomalies  of  the  Cord.  Placenta  Marginata;  Placenta  Circumvallata:  When  the 
chorion  lasve  begins  within  instead 
of  at  the  border  of  the  placenta  the 
latter  necessarily  exhibits  a  free 
margin  and  is  known  as  a  pla- 
centa marginata.  When  the 
chorion  forms  a  rigid  annular  fold 
at  the  inner  limit  of  the  margin, 
we  have  a  so-called  placenta  cir- 
cumvallata. These  conditions  have 
their  inception  before  the  placenta 
has  arrived  at  its  normal  super- 
ficial growth.  The  outermost  villi 
penetrate  into  the  substance  of  the 
decidua  vera,  so  that  the  latter  is 
split,  its  upper  segment  becoming 
a    part    of    the    refiexa.     Through 

some  inflammatory  process  in  the  latter  with  resulting  fibroid  induration, 
the  lateral  expansion  of  the  placenta  is  accomplished  in  an  abortive  fashion, 
the  outer  portion  being  without  its  normal  chorionic  investment.     During  the 


Fig.   263. — Placenta   Dimidiata. — (Ahlfeld.) 


Fig.  264. — Diagram  Representing  the 
Formation  of  Marginal  Placenta 
Previa.  The  ovum  becomes  fixed  to 
one  side  of  the  internal  os  ;  the  chorion 
and  placenta  form,  and  a  marginal  pla- 
centa pr3via  results. — (Ahlfeld.) 


Fig.  265. — Diagram  Representing  thh 
Formation  of  a  Central  Placenta 
Previa.  The  ovum  becomes  fixed  just 
over  the  internal  os;  the  chorion  and 
placenta  form,  and  a  central  placenta 
praevia  results. — (Ahlfeld.) 


sclerotic  contraction  of  the  inflammatory  zone  in  the  reflexa,  the  chorion  is  forced 
into  a  sharp  fold  at  its  junction  with  the  surface  of  the  placenta  (placenta 
circumvallata).       As  in  the   case   of  most   of  these  placental   anomalies,   the 


214 


PATHOLOGICAL  PREGNANCY. 


essential  cause  of  the  marginate  and  circumvallate  forms  is  to  be  found  in  a 
diseased  endometrium,  which  is  responsible  for  the  pathological  condition  of 
the  refiexa.  A  higher  degree  of  the  process  which  causes  the  placenta  mar- 
ginata  should,  in  theory  at  least,  interfere  with  the  growth  of  the  placenta 
to  such  an  extent  as  to  cause  the  death  of  the  fetus.  The  clinical  significance 
of  these  placental  anomalies  is  twofold :  ( i )  The  amnion  and  chorion  are  often 
intimately  adherent,  so  that  during  expulsion  of  the  after-birth  the  chorion 
may  be  torn  from  the  placenta  and  left  behind.     (2)  The  complications  pro- 


^xTlSLD^r 


Fig.  266. — Diagrams  to  Represent  the  Varieties  of  Placenta  Pr.«via  According 
TO  THE  Definitions  Set  Forth  in  this  Work. — {Author's  classification.) 


duced  by  other  placental  anomalies,  such  as  incomplete  detachment,  retention, 
and  atonic  hemorrhages,  are  frequently  encountered  here. 

(5)  Anomalies  of  Insertion;  Placenta  Previa. — Definition. — The 
placenta  is  said  to  be  prsevia  when  it  is  attached  to  any  portion  of  the  lower 
uterine  segment,  and  since  dilatation  of  the  segment  is  necessarily  followed 
by  hemorrhage  from  separation  of  the  placenta,  the  condition  is  sometimes 
called  unavoidable  hemorrhage.  Hemorrhages  of  pregnancy  in  the  first  months 
are  usually  due  to  abortion,  menstruation,  or  lesions  of  the  cervix,  and  are 


ANOMALIES  AND   DISEASES  OF  THE   PLACENTA.  215 

not  profuse.  In  the  last  three  months  they  are  almost  always  due  to  a  pre- 
mature detachment  of  a  normally  or  abnormally  inserted  placenta.  The  former 
is  considered  under  Accidental  Hemorrhage.  Placenta  praevia  has  also  been 
defined  as  a  localization  of  the  placenta  over  the  internal  os  when  the  latter 
is  dilated  (Fig.  266). 

Frequency. — In  estimating  the  frequency  of  this  anomaly  as  of  others  in 
obstetrics,  account  must  be  taken  of  the  hospital  service  or  private  practice 
from  which  the  conclusions  are  drawn.  Thus,  we  find  the  proportion  given 
as  high  as  i  in  250  and  as  low  as  i  in  1000.  In  an  indoor  and  outdoor  hospital 
service,  and  in  a  private  practice  in  which  no  emergencies  and  consultation 
cases  are  seen,  the  latter  figure  is  not  far  from  correct;  while  where  einergency 
and  consultation  cases  are  counted,  the  proportion  may  easily  approach  the 
former  figures.  Statistics  exhibit  great  irregularities.  In  some  years  the 
condition  is  so  frequent  as  almost  to  simulate  an  epidemic.  In  2200  preg- 
nancies I  found  that  the  diagnosis  of  placenta  prasvia  was  made  in  9  cases, 
or  0.40  per  cent.,  or  i  in  244  cases.  Three,  or  33.33  per  cent.,  were  in  primiparae, 
and  6,  or  66.66  per  cent.,  were  in  multiparae.  One  thousand  of  these  patients  were 
confined  at  the  New  York  Maternity,  where  no  emergency  cases  are  received, 
and  1200  at  the  Mothers'  and  Babies'  Hospital  at  a  time  when  few  cases  out- 
side the  regular  hospital  service  were  cared  for. 

Varieties. — In  placenta  prcevia  centralis  the  placenta  completely  covers  the 
lumen  of  the  os  after  dilatation  is  complete.  This  form  is  very  rare,  and  the 
placenta  is  placed  to  a  great  extent  to  one  side  of  the  uterus — especially  the 
right  side  (Fig.  266).  In  placenta  prcevia  partialis  the  placenta  partially  covers 
the  lumen  of  the  os  after  complete  dilatation,  and  there  is  more  placental  sub- 
stance on  one  side  of  the  os  than  on  the  other  (Fig.  266).  In  placenta  prcevia 
lateralis  or  marginalis  the  placenta  does  not  reach  beyond  the  margin  of  the 
internal  OS.  This  is  the  most  common  form  (Fig.  266).  In  the  lateral  variety 
the  placenta  is  situated  on  the  lateral  surface  of  the  lower  part  of  the  uterus, 
not  quite  reaching  the  edge  of  the  internal  os.  On  dilatation  of  this  lower 
uterine  segment  the  placenta  may  be  separated  with  very  little  loss  of  blood. 
In  the  marginal  variety  the  placenta  stretches  down  to,  but  not  over,  the  internal 
OS.  These  several  varieties  can  be  arranged  again  in  two  groups — complete 
and  incomplete.  The  complete  variety  comprises  the  placenta  praevia  cen- 
tralis, while  the  three  varieties  remaining  are  embraced  under  the  term  in- 
complete. 

Etiology. — Placenta  previa  is  much  more  common  in  multigravidse  than  in 
primigravidffi,  the  proportion  being  about  six  to  one.  Among  the  various 
causes  which  may  result  in  faulty  attachment  of  the  ovum  are  conditions  lead- 
ing to  enlargement  and  relaxation  of  the  uterus  and  to  changes  of  shape ;  e.  g., 
multiparity,  multiple  pregnancy,  and  uterine  malformations;  also  conditions 
leading  to  changes  in  the  uterine  mucosa,  as  endometritis,  abortions,  and  tumors. 
It  seems  more  common  in  the  poorer  classes;  owing  probably  to  hard  work  and 
subinvolution  of  the  uterus.  Abnormally  low  position  of  the  Fallopian  tubes 
and  abnormal  size  of  the  uterus  are  etiological  factors.  A  diseased  endome- 
trium is  probably  the  fundamental  cause.  It  is  believed  by  some  that  in  a 
threatened  abortion  the  ovum  may  be  arrested  in  its  descent  and  become  at- 
tached near  or  at  the  cervix.  Hofmeier  and  Kaltenbach  propose  another 
theory, — that  the  placenta  is  developed -both  in  the  decidua  basalis  and  the 
decidua  reflexa;  adhesion  occurs  between  the  refiexa  and  vera,  and  therefore  the 
placenta  may  be  over  the  internal  os. 

Cause  of  the  Hemorrhage. — It  is   necessary  to   understand  thoroughlv  the 


216  PATHOLOGICAL  PREGNANCY. 

anatomy  of  the  parts  concerned  in  order  to  form  a  true  idea  of  their  mechanism, 
both  normal  and  abnormal. 

According  to  our  present  understanding  of  its  morphology,  the  pregnant 
uterus  consists  of  three  parts  which  are  distinct  both  anatomically  and  physio- 
logically. The  upper  part  or  body  is  divided  into  two  sections  by  Bandl's 
ring,  while  the  cervix  forms  the  third  part  (see  Part  IV).  The  physiological 
function  of  the  cervix  is  active  only  during  labor  itself. 

The  normal  arrest  of  the  ovum  is  a  little  below  the  uterine  opening  of 
the  tubes  and  above  Bandl's  ring.  This  statement  is  upheld  by  the  fact 
that  the  placenta  is  nearly  always  attached  to  the  side  of  the  uterus.  The 
fundal  implantation  is  very  rare.  The  area  of  attachment  is  very  small  in 
early  pregnancy  and  the  development  of  the  placenta  will  conform  to  the  growth 
of  that  part  of  the  uterus  to  which  it  has  attached  itself.  Above,  the  wall  of 
the  uterus  becomes  thicker  and  ready  for  its  function — contraction;  below,  it 
becomes  thinner  and  expands.  In  case  the  placenta  is  low  down  it  will  for  a 
time  conform  to  the  uterine  changes.  First  it  will  enlarge  at  the  point  of  at- 
tachment, then  it  will  expand  to  a  certain  degree;  but  when  the  limit  is  reached, 
then  hemorrhage  will  occur.  If  the  attachment  is  very  extensive  or  particu- 
larly firm,  there  will  occur  partial  rupture  of  the  placental  substance,  or  the 
placenta  will  separate  from  its  base.  During  labor,  as  dilatation  continues, 
the  breech  between  the  uterine  wall  and  the  placenta  becomes  gradually 
greater  and  greater:  with  each  contraction  of  the  uterus  new  placental  tissue 
is  lacerated.  The  retraction  of  the  uterus  from  the  placenta  is  most  clearly 
seen  in  those  cases  in  which  only  a  small  edge  of  placenta  can  be  felt  when 
the  cervix  begins  to  dilate,  but  in  which  nearly  the  whole  placenta  is  lowered 
when  dilatation  is  completed.  But  this  changed  position  is  not  so  much 
affected  by  the  descent  of  the  placenta  as  by  the  ascent  of  the  lower  part  of 
the  uterus. 

The  parturient  uterus  is  characterized  by  three  properties :  contractility  and 
retractility  of  the  upper  segment,  dilatability  of  the  lower  segment.  These  ex- 
plain the  entire  mechanism.  This  theory  seems  to  be  the  most  satisfactory  of 
those  advanced,  and  is  founded  upon  the  supposition  that  the  lower  segment 
of  the  uterus  belongs  to  the  body  and  not  to  the  cervix.  The  idea  is  generally 
current  that  true  decidua  is  never  found  on  the  mucous  membrane  of  the  cer- 
vix, so  that  the  placenta  cannot  primarily  be  implanted  there.  This  has  not 
yet  been  positively  proved. 

The  low  implantation  of  the  placenta  undoubtedly  renders  it  more  liable 
to  detachment  from  mechanical  causes — such  as  shocks,  jars,  etc. — than  when 
it  is  normally  situated.  In  the  upright  position  of  the  woman,  moreover,  the 
blood-pressure  is  greater  in  the  placenta  when  it  is  praevia.  The  decidua  refiexa 
may  grow  downward  and  become  attached  over  the  internal  os. 

Pathology. — The  placenta  is  generally  the  subject  of  malformation;  its  form 
is  irregular;  it  is  thinner  and  covers  a  larger  surface  than  the  normally  situated 
placenta;  the  decidual  part  is  unevenly  developed,  being  very  thick  above 
and  thin  below;  the  upper  part  is  also  very  firmly  attached  to  its  bed,  while 
the  attachment  of  the  lower  part  is  very  slender.  The  placenta  may  be  bilobed 
or  there  may  be  a  placenta  succenturiata,  causing  errors  in  diagnosis.  The 
forms  which  it  may  assume  are  varied.  The  adhesions  between  the  pla- 
centa and  the  uterine  wall  are  often  abnormal,  causing  complications  in  its 
delivery.  The  insertion  of  the  cord  is  also  abnormal,  and  it  is  not  often  found 
centrally  attached,  but  is  apt  to  be  nearer  one  side  than  the  other.  Prolapse 
of  the  cord  is  consequently  not  uncommon. 


ANOMALIES  AND   DISEASES   OF   THE  PLACENTA. 


217 


Symptoms. — The  principal  symptom  is  hemorrhage.  It  occurs  without 
warning  and  varies  from  a  few  drops  to  an  amount  sufficient  to  produce 
grave  anemia;  the  attacks,  however,  are  usually  slight  at  first  and  increase  in 
severity;  and  the  time  of  the  hemorrhage  often  corresponds  to  a  menstrual 
epoch.  It  occurs  at  any  time  of  pregnancy,  from  the  beginning  of  the  third 
month  to  delivery;  it  is  most  frequent  in  the  last  month,  though  it  may  be 
looked  for  soon  after  the  sixth  month.  The  more  nearly  central  the  placenta, 
the  earlier  will  be  the  occurrence  of  hemorrhage.  Most  cases  of  so-called 
menstruation  in  pregnancy  are  due  to  the  low  implantation  of  the  placenta. 
There  is  usually  no  show  of  blood  in  the  marginal  variety  till  the  beginning  of 
labor. 

During  pregnancy  the  amount  of  blood  lost  is  not  so  apt  to  be  dangerous, 
but  at  the  completion  of  gestation  or  during  the  commencement  of  labor  the 
loss  of  blood  may  be  tremendous,  the 
constitutional  symptoms  of  hemor- 
rhage supervening,  and  within  a  few 
minutes  the  patient's  life  may  be 
placed  in  great  danger,  death  occur- 
ring within  a  few  moments  of  the  be- 
ginning of  the  hemorrhage.  The  hem- 
orrhage ceases  when  (i)  the  separa- 
tion of  the  placenta  is  completed;  also 
generally  after  (2)  the  rupture  of  the 
membranes,  for  then  (3)  the  present- 
ing part,  of  the  placenta  itself  is  forced 
down  upon  the  bleeding  uterine  sin- 
uses, closing  their  openings. 

When  labor  has  commenced,  each 
contraction  of  the  uterus  causes  fresh 
portions  of  the  placenta  to  become 
detached,  and  consequently  fresh  ves- 
sels are  torn  and  left  open.  The  ten- 
dency of  these  contractions,  however, 
in  all  forms  of  hemorrhage  is  to  con- 
strict the  open  mouths  of  the  uterine 
sinuses  and  so  to  control  the  hemor- 
rhages. The  apparent  increase  of  the 
bleeding  in  placenta  praevia  during  a 
uterus  forcing  out  from  the  organ  blood  which  had  already  escaped  during  the 
interval.  In  one  way,  up  to  a  certain  point,  contractions  do  favor  hemorrhage 
by  detaching  fresh  portions  of  the  placental  tissue,  but  the  actual  loss  of  blood 
comes  from  the  uterine  sinuses  during  the  interval  and  not  during  the  contrac- 
tion. ;<,yi 

Course  of  Labor. — The  first  stage  is  liable  to  be  delayed,  since  the  pres- 
ence of  the  placenta  interferes  with  the  cervical  dilatation;  unless  the 
patient  is  exhausted  by  hemorrhage,  however,  the  labor  may  progress  rapidly 
after  the  presenting  part  has  entered  the  cervix,  since  the  latter  is  usually 
soft  and  elastic.  Rigidity  of  the  cervix  is  sometimes  present  (12  per  cent, 
of  the  cases,  Muller). 

Diagnosis. — Early  in  pregnancy  the  diagnosis  is  impossible  unless  the  pla- 
centa is  actually  palpated,  but  in  the  last  third  of  gestation,  the  character 
of  the  hemorrhage  and,  after  dilatation  has  been  secured,  the  palpation  of  the 


\ 


Fig.  267. — Placenta  Previa  in  Twin  Preg- 
nancy.—  (Hojmeier.) 


pain"  is  due  to  the  contractions  of  the 


218  PATHOLOGICAL   PREGNANCY. 

placenta,  determine  the  diagnosis.  Inspection  and  auscultation  have  no  part 
in  the  diagnosis  of  placenta  praevia.  Little  or  nothing  is  to  be  gained  by 
abdominal  palpation,  but  vaginal  exploration  is  most  valuable.  The  only- 
positive  evidence  of  the  condition  is  obtained  by  palpating  the  placenta  with 
the  fingers  passed  through  the  os.  During  labor  this  is  best  performed  in 
the  intervals  between  the  pains,  and,  fortunately,  in  the  last  months  of  the 
pregnancy  the  cervical  canal  is  usually  yielding  and  patulous  and  offers  little 
resistance  to  the  finger  in  the  class  of  patients  most  often  suffering  from  this 
anomaly — namely,  multigravidae.  Before  dilatation  of  the  os,  by  palpating 
the  lower  uterine  segment  through  one  of  the  vaginal  fornices,  the  placenta 
may  be  made  out  through  the  uterine  wall  between  the  fingers  and  the  pre- 
senting fetal  part.  Ballottement  will  be  obscure  or  absent  altogether,  and 
the  large  placental  vessels  and  those  of  the  lower  segment  may  be  distinctly 
felt  pulsating  under  the  finger.  The  cervix  and  vaginal  fornices  are  softer 
than  normal  and  have  a  boggy  feel,  due  to  the  increased  blood-supply,  and 
the  presenting  part  is  with  difficulty  made  out  through  the  placental  substance. 
These  signs  are  often  more  marked  on  one  side  of  the  cervix  than  the  other. 
After  dilatation  of  the  cervix,  if  the  placenta  is  centrally  attached,  the  whole 
internal  os  will  be  covered  over  by  a  thick,  boggy  mass,  soft  and  granular, 
distinguished  from  coagulum  by  its  consistency  and  its  resistance  to  pressure 
of  the  finger  (Fig.  266).  Through  this  placental  mass  the  presenting  fetal 
part  may  be  felt,  but  far  less  distinctly  than  in  the  normal  condition.  If 
the  placental  attachment  is  only  partial,  the  bag  of  waters  will  be  felt,  and 
above  it  the  head,  occupying  one  part  of  the  internal  os,  while  the  rest  of  the 
aperture  will  be  covered  by  the  placental  mass  (Fig.  266).  If  the  attachment 
is  marginal,  only  the  thick  edge  of  the  placenta  will  be  made  out  near  the 
rim  of  the  internal  os  (Fig.  266). 

Differential  Diagnosis. — The  condition  is  to  be  distinguished  from  acci- 
dental hemorrhage  and  from  rupture  of  the  uterus.  (See  Accidental  Hemor- 
rhage.) 

Prognosis. — Death  of  the  mother  is  due  to  hemorrhage  and  sepsis.  The 
nearer  to  the  time  of  labor  the  hemorrhage  occurs,  the  better  the  prognosis, 
as  dilatation  and  emptying  of  the  uterus  can  more  readily  be  accomplished. 
For  the  same  reason  the  prognosis  is  better  in  multigravids  than  in  primi- 
gravidffi,  and  during  labor  than  in  pregnancy.  Again,  the  danger  is  greater 
for  both  mother  and  fetus  the  more  centrally  the  placenta  is  placed,  for  when 
centrally  located  a  greater  number  of  uterine  vessels  will  be  exposed  before 
labor  can  terminate.  There  is  danger  also  of  hemorrhage  after  birth,  as 
the  lower  segment,  flabby  and  inert  from  the  muscular  atrophy  which 
follows  the  distention  caused  by  the  abnormal  placenta,  does  not  completely 
occlude  the  vessels  left  gaping  after  detachment  of  the  latter.  The  cervix 
and  lower  segment  should  be  very  carefully  guarded,  as  mechanical  manipu- 
lations— especially  in  rapid  dilatations  and  extractions — may  fatally  tear  these 
parts.  (See  Part  V.)  Death  may  supervene  suddenly  after  the  bleeding  has 
entirely  ceased,  from  the  great  constitutional  depression  which  follows  the  loss 
of  blood. 

The  increased  risk  of  septic  infection  is  due  (i)  partly  to  the  greater  ten- 
dency which  the  vessels  have  for  absorption  as  a  consequence  of  their  emptiness 
following  the  hemorrhage;  (2)  partly  to  the  low  position  of  the  placental  site, 
it  thus  being  more  exposed  to  external  influences;  and  (3)  lastly  to  the  manual 
or  instrumental  interference  at  the  placental  site  that  may  have  been  found 
necessary  during  delivery. 


ANOMALIES  AND   DISEASES  OF  THE  PLACENTA. 


219 


The  less  the  bleeding  is  accompanied  by  uterine  contractions,  the  graver 
is  the  prognosis,  since  labor  pains  always  tend  to  close  the  mouths  of  the  blood- 
vessels. Lastly,  the  greater  -th©  anemia  that  is  brought  about  before  actual 
labor,  the  greater  the  risk;  since  some  operation  may  be  demanded  to  hasten 
delivery  which  the  woman  in  her  weakened  condition  is  little  able  to  bear. 
There  is  more  hope  of  saving  the  child  than  many  authors  admit,  and  this  fact 
should  be  kept  constantly  in  mind.  In  early  gestation  the  cause  of  fetal  death 
is  placental  apoplexy  followed  by  painless  abortion.  In  these  cases  the  ovum  is 
usually  expelled  entire  (Fig.  268).  Later  on,  after  the  child  has  become  viable, 
the  chief  danger  is  as- 
phyxia from  the  loss  of  ma- 
ternal blood  as  a  conse- 
quence of  separation  of  the 
placenta.  Other  causes  of 
fetal  mortality  are  ( i )  mal- 
position, the  placenta  in 
the  lower  uterine  segment 
not  allowing  the  head  to 
.present,  the  shape  of  the 
uterus  also  being  distorted ; 
(2)  premature  delivery 
found  necessary  to  save  the 
mother's  life,  and  (3)  ver- 
sion, which  in  many  cases 
is  performed  to  control 
hemorrhage  or  to  effect 
speedy  delivery.  Hemor- 
rhage and  inanition  may 
also  be  causes  of  fetal 
death.  Malpresentation 
frequently  occurs  owing  to 
the  relaxed  condition  of  the 
uterus  and  the  softening 
and  stretching  of  the  lower 
uterine  segment,  and  to 
the  fact  that  the  placenta 
usually  occupies  the  space 
filled  by  the  presenting 
part.  Miiller  found  in  1 1 48 
cases  272  transverse  pres- 
entations and  107  breech 
presentations.     Premature 

labor  and  premature  rupture  of  the  membranes  are  common  in  this  condition. 
In  our  9  cases  of  placenta  prsevia  already  cited,  there  was  one  maternal  death, 
due  to  rupture  of  the  uterus  from  rapid  manual  dilatation  of  the  cervix.  The 
maternal  mortality  was  11. 11  per  cent.;  the  fetal  mortality,  22.23  percent.  Of 
the  9  cases,  4  were  treated  by  manual  dilatation  of  the  cervix  followed  by  im- 
mediate version  and  extraction;  2  by  podalic  version;  i  by  manual  dilatation 
and  forceps,  and  i  by  spontaneous  delivery. 

Summary  of  Prognosis:  The  causes  of  the  great  maternal  mortality  are  (i) 
hemorrhage;  (2)  septicemia;  (3)  inflammations — metritis,  peritonitis,  phle- 
bitis; (4)  shock  of  version,  which  operation  is  generally  indicated,  and  is,  in 


Fig.  268. — Partial  Placenta  Pr.-evia  at  Four  and  a 
Half  Months.  Spontaneous  exptilsion  of  an  unrup- 
tured ovum  with  moderate  hemorrhage. — (Author's  col- 
lection.) 


220 


PATHOLOGICAL  PREGNANCY. 


many  cases,  performed  when  the  woman  is  in  an  exhausted  state  from  the 
loss  of  blood  or  previous  attempts  at  delivery  through  an  imperfectly  dilated 
OS.  The  causes  of  fetal  tnortality  are  (i)  asphyxia;  (2)  prematurity;  (3)  version; 
(4)  malpresentations ;  (5)  inspiration  pneumonia. 

Treatment. — There  is  no  preventive  treatment  of  this  condition.  When  the 
diagnosis  of  placenta  praevia  is  assured,  the  broad  rule  is  to  empty  the  uterus  at 
once.     This  is  at  least  the  theoretical  aspect  of  the  question.     In  practice,  how- 


FiG.  2  69. — Central  Placenta  Previa  at  the  Sixteenth  Week.  Sudden  and  spontaneous 
hemorrhage  and  death  within  six  hours  from  acute  anemia.  Blood  loss  estimated  at 
several  pints.  Placenta  membranacea  is  also  present.  The  membranes  are  unruptvured. 
(^  natural  size.) — (Author's  collection.) 


ever,  numerous  conditions  assert  themselves  which  constitute  exceptions.  A 
certain  number,  probably  constantly  decreasing,  of  practitioners  regard  inter- 
vention before  the  seventh  month  as  meddlesome.  Statistics  show  that  fatal 
hemorrhage  before  this  period  is  rare.  Fig.  269  is  a  specimen  in  my  collection 
from  a  woman  pregnant  at  the  sixteenth  week,  with  placenta  praevia,  who  died 
of  uterine  hemorrhage  and  acute  anemia  within  six  hours  after  the  appearance 
of  the  first  bleeding.     The  blood  loss  was  estimated  at  several  pints.     The 


ANOMALIES   AND   DISEASES   OF  THE  PLACENTA. 


221 


minority,  who  dissent  from  the  routine  practice  of  emptying  the  uterus  at  all 
times,  hold  that  the  interruption  of  pregnancy  before  viability  is  unnecessary, 
unless  for  special  indication,  such  as  profuse  hemorrhage.  They  claim  also 
that  if  the  mother  is  in  no  danger,  the  fetus  should  be  given  a  chance  of  sur- 
vival. The  majority,  on  the 
other  hand,  maintain  that  the 
mother  is  always  liable  to  a  fatal 
hemorrhage;  that  moderate  loss 
of  blood  up  to  the  time  of  viabil- 
ity produces  a  weakening  effect 
on  the  mother;  and,  finally,  that 
the  chances  of  the  fetus  for  sur- 
vival are  so  slight  that  they 
should  be  disregarded.  To  the 
dissent  of  a  portion  of  the  pro- 
fession must  be  added  the  scru- 
ples of  the  prospective  mother 
and  her  relatives.  The  idea  of 
terminating  the  pregnancy  with- 
out regard  to  the  right  of  the 
fetus  may  be  repugnant,  and  an 
heir  may  be  greatly  desired  for 
more  reasons  than  one.  The 
mother,  too,  may  be  willing  to 
accept  the  risk.  In  such  a  case 
the  most  the  practitioner  can  do 
is  to  explain  the  dangers  as  fully 
as  possible,  and  perhaps  to  call 
a  consultation;  the  joint  opinion 
of  two  practitioners  should  go 
far  toward  persuading  the 
woman  to  choose  the  wise 
course. 

If  the  condition  is  recognized 
before  the  seventh  month,  and 
the  aim  is  to  continue  the  preg- 
nancy, the  woman  must  be 
made  to  lead  a  quiet  life,  men- 
tally and  physically.  She  should, 
as  far  as  possible,  avoid  all  mus- 
cular effort,  such  as  straining  at 
stool.  Coitus  should  be  inter- 
dicted. The  diet  should  be  light. 
If  moderate  hemorrhage  is  pres- 
ent, she  should  lie  in  bed  till  all 
bleeding  ceases.  For  uterine  con- 
tractions     opiates     should     be 

given.  If  the  symptoms  are  more  severe,  the  patient  should  be  placed 
upon  the  full  regimen  for  threatened  abortion.  The  foot  of  the  bed 
should  be  raised  and  cold  applications  made  to  the  pelvis.  The  ex- 
pectant    method     requires    the    constant    presence    of    an    attendant    who    is 


'nUrnal  Os 


External  Os 


Fig 


270. 


Frozen  Section  of  a  Case  of  Central 
Placenta  Previa  in  which  One  Leg  Has  Been 
Brought  Down  According  to  Braxton-Hicks's 
Method  and  the  Half-breech  Used  as  a  Tam- 
pon TO  Plug  the  Lower  Uterine  Segment  and 
the  Cervical  Canal. — (Leopold.) 


requires 
able  to  deal  with  a  profuse  hemorrhage  should  such  occur. 


Only  in  the  most 


222 


PATHOLOGICAL  PREGNANCY. 


exceptional  circumstances  should  expectancy  in  placenta  prasvia  be  con- 
sidered either  in  pregnancy  or  labor.  To  be  sure,  I  have  observed  several 
spontaneous  safe  confinements  in  placenta  prasvia  of  the  lateral  or  marginal 
variety,  and  been  able  to  demonstrate  the  condition  to  hospital  staffs,  and  spon- 
taneous delivery  in  premature  cases  may  exceptionally  occur,  without  dangerous 
blood  loss  in  the  central  variety,  by  the  placenta  being  born  before  or  with  the 
fetus  (Fig.  268).  However,  because  of  the  danger  of  an  unexpected,  profuse, 
and  possibly  fatal  hemorrhage,  in  either  pregnancy  or  labor,  always  present  in 
placenta  prasvia,  the  uterus  should  be  emptied  as  soon  as  possible  after  the 
diagnosis  of  the  condition  is  positively  made. 


Fig.  271. — Vaginal  and  Cervical  Tampon  in  Central  Placenta  Previa.     Foiir-inch 
sterile  gauze  used  for  the  tampon  and  a  T-bandage  applied. 


In  either  pregnancy  or  labor  there  are  three  indications  that  must  be  met : 
(i)  The  first  stage  of  labor  must  be  rendered  as  short  as  possible  by  artificial 
dilatation  of  the  cervix.  (2)  Hemostasis  must  be  as  complete  as  possible.  (3) 
The  second  stage  should  be  abbreviated. 

In  pregnancy  labor  should  first  be  induced,  and  as  soon  as  the  cervix  has 
been  effaced,  the  indications  for  management,  as  just  stated,  carried  out.  In 
the  absence  of  hemorrhage,  and  in  lateral  placenta  prsevia,  labor  can  be  brought 
on  by  the  introduction  of  one  of  the  smaller  modifications  of  the  Champetier  de 
Ribes  bags.  For  the  introduction  of  the  bag  sufficient  dilatation  can  be  secured 
by  dilating  the  cervix  with  one  finger  or  with  the  Goodell  type  of  instrument. 
In  the  presence  of  hemorrhage  and  in  primigravidous  women  with  rigid  cervices 


ANOMALIES  AND  DISEASES  OF  THE   PLACENTA.  223 

it  is  better  to  tampon  the  cervical  canal  and  vagina  tightly  with  sterile  gauze. 
This  procedure  temporarily  checks  the  bleeding,  and  rarely  fails  to  cause  a  draw- 
ing up  of  the  vaginal  cervix,  if  not  to  induce  active  labor  (Fig.  271).  At  all 
events,  sufficient  softening  and  dilatation  are  produced  to  permit  a  further  rapid 
dilatation  and  delivery,  or  other  manoeuvre  determined  upon. 

1.  Rapid  Dilatation. — In  pregnancy  or  labor  the  cervix  being  in  a  readily 
dilatable  condition,  the  best  results  for  mother  and  child  will  be  obtained  by 
rendering  the  first  stage  as  short  as  possible,  thus  minimizing  the  amount  of 
blood  loss.  This  is  accomplished  by  instrumental  dilatation  with  a  dilator  of 
the  Bossi  type  or  by  manual  dilatation.  For  the  latter,  I  firmly  beheve  the 
bimanual  method  is  far  superior  to  the  one-handed  method,  because  by  it  the 
fingers  cause  no  unnecessary  separation  of  the  placenta,  which  the  fingers  of  one 
hand  passed  into  the  os  are  bound  to  accomplish  in  complete  placenta  praevia. 
Dilators  of  the  Bossi  type  are  particularly  well  adapted  to  cases  of  rigid  cervix, 
fortunately  rarely  encountered  in  placenta  praevia.  The  Champetier  de  Ribes 
bag  or  its  modifications  rarely  have  a  place  here  in  accelerating  the  first  stage 
or  in  controlling  hemorrhage,  and  never  in  central  implantation  of  the  placenta, 
as  separation  of  the  placenta  and  concealed  hemorrhage  will  result  from  their 
use. 

2.  Hemostasis. — At  any  time  after  the  os  is  sufficiently  dilated  to  admit  two 
fingers,  we  always  have  a  sure  method  of  controlling  hemorrhage  in  the  Braxton- 
Hicks  manoeuvre  of  combined  version.  (See  Operations.)  (Fig.  270.)  If  in  the 
midst  of  an  instrumental  or  manual  cervical  dilatation  bleeding  becomes  too 
free,  one  leg  of  the  fetus  should  be  brought  down  by  the  Hicks  method,  and  the 
breech  of  the  fetus  used  as  a  tampon  to  control  further  bleeding.  It  is  my  cus- 
tom after  the  leg  is  brought  out  of  the  vagina,  to  attach  a  sling  to  it,  and  have 
an  assistant  make  traction  on  the  latter.  I  then  proceed  to  complete  the  cervi- 
cal dilatation  by  the  bimanual  method  (Part  X)  and  empty  the  uterus.  It  is 
under  such  circumstances,  namely,  when  the  thigh  of  the  fetus  plugs  the  cervix, 
that  the  bimanual  method  of  dilatation  is  the  only  one  feasible  (Part  X).  Should 
the  bleeding  become  alarming  after  almost  complete  cervical  dilatation,  it  is 
usually  best  to  perform  the  ordinary  direct  podalic  version,  and  proceed  with 
the  breech  extraction  forthwith.  Rupture  of  the  membranes  as  a  means  to  con- 
trol hemorrhage  is  uncertain,  and  should  be  deferred  until  late  in  the  first  stage. 
My  experience  does  not  lead  me  to  recommend  its  use. 

3.  Shortening  of  the  Second  Stage. — I  believe  the  best  results  for  both  mother 
and  child  are  secured  by  rendering  the  second  stage  as  short  as  is  consistent  with 
the  integrity  of  the  mother's  soft  parts.  This  should  apply  even  to  those  cases 
in  which  bleeding  has  been  controlled  by  Hicks 's  bipolar  version  method,  because 
the  danger  of  internal  concealed  hemorrhage  is  always  present.  One  should 
therefore  elect  forceps,  podaHc  version,  or  breech  extraction,  according  to  the 
indications  for  each  present.  After  profuse  hemorrhage  a  patient  will,  when  first 
seen,  often  be  found  to  be  suffering  from  acute  anemia  or  collapse,  and  possibly 
she  is  at  the  moment  losing  little  or  no  blood.  It  is  advisable,  in  such  cases,  to 
tightly  tampon  the  lower  uterine  segment,  cervix,  and  vagina  with  sterile  gauze, 
and  wait  until  reaction  has  been  secured  by  infusion,  stimulants,  and  nutrient 
enema  before  completing  dilatation  or  dehvery  (Fig.  271).  In  the  case  of  a 
dilated  or  dilatable  os  and  a  collapsed  patient  it  is  justifiable  partially  to  detach 
the  placenta  from  the  zone  of  dangerous  attachment,  or  even  entirely  to  detach 
and  dehver  it,  tightly  to  tampon  the  lower  segment  and  vagina,  and  to  rally 
the  patient  before  proceeding  to  the  delivery  of  the  child. 

CcBsarean  Section. — Eclampsia  and  placenta  praevia  have  occasionally  been 


224  PATHOLOGICAL  PREGNANCY. 

looked  upon  as  indications  for  Caesarean  section,  by  reason  of  the  high  maternal 
and  fetal  mortality  in  both"  these  conditions.  I  admit  that  the  operation,  or  its 
substitute,  vaginal  Cassarean  section,  is  occasionally  indicated  in  eclampsia,  for 
the  reason  that  eclampsia  is  more  common  in  primigravidae  than  in  multigravidae, 
and  hence  the  cervix  is  more  often  persistently  rigid  in  eclampsia  than  in  placenta 
praevia,  but,  I  believe,  it  is  safe  to  state  that  placenta  praevia  will  rarely  demand 
Caesarean  section. 

Management  of  the  Third  Stage. — Manual  removal  of  the  placenta  is  necessary 
only  when  after  delivery  the  hemorrhage  still  persists.  Sometimes  bleeding 
continues  after  the  placenta  is  born,  and  even  when  the  uterus  is  well  con- 
tracted. In  this  variety  of  post-partum  hemorrhage  the  management  does 
not  differ  from  that  of  the  ordinary  forms.  (See  Post-partum  Hemorrhage.) 
It  should  be  remembered  that  the  low  situation  of  the  placental  site  predisposes 
post  partum  to  hemorrhage  and  sepsis.  As  a  prophylaxis  against  the  former, 
especially  after  much  blood  loss  prior  to  and  during  labor,  the  application 
of  the  uterine  and  vaginal  gauze  tampon  is  of  great  service. 

After-treatment. — All  danger  is  not  over  after  expulsion  of  the  placenta. 
The  patient  may  be  threatened  with  fatal  syncope  and  must  be  kept  recumbent 
with  head  low.  If  the  indications  arise,  she  should  be  given  alcoholic  stimu- 
lants by  the  mouth,  and  ether  or  caffeine  hypodermically,  with  saline  infusion. 
Vomiting,  which  is  common  after  placenta  previa,  should  be  met  with  cracked 
ice,  and,  if  necessary,  nutrient  enemata. 

2.  Injuries. — Premature  Detachment  of  a  Normally  Situated  Pla- 
centa. Accidental  Hemorrhage. — Definition. — Accidental  hemorrhage  is 
generally  understood  to  mean  one  which  occurs  from  the  separation  of  a  nor- 
mally situated  placenta,  in  contradistinction  to  the  unavoidable  hemorrhage 
of  placenta  praevia.  These  terms  may  be  considered  misnomers,  as  not  infre- 
quently the  etiology  is  almost  the  same.  The  separation  may  be  partial  or 
complete,  the  former  variety  being  far  more  common.  It  is  one  of  the  gravest 
conditions  met  with  in  obstetrics.  Clinically  there  are  two  classes,  those  in 
which  contractions  of  the  uterus  are  present,  and  those  in  which  they  are  absent. 
Quite  recently  Holmes,  of  Chicago,  has  published  a  thesis  *  based  upon  the 
analysis  of  200  cases  from  literature.  He  advocates  the  use  of  a  new  name 
for  this  condition:  viz.,  ablatio  placentce.  He  claims  that  the  latter  occurs 
much  more  frequently  than  has  been  believed. 

Frequency. — According  to  Holmes,  the  ratio  of  ablatio  placentae  to  normal 
labor  must  be  re-stated.  In  clinics  where  some  effort  has  been  made  to  recog- 
nize and  record  the  existence  of  this  complication  something  like  i  :  200  appears 
to  be  the  prevailing  proportion. 

Varieties. — There  are  two  ways  in  which  this  hemorrhage  may  declare  itself: 
it  may  be  frank  or  open,  or  hidden  or  concealed  (Fig.  272) ;  the  former  being  the 
more  usual,  while  now  and  then  the  two  forms  are  present  in  the  same  case. 
The  point  of  separation  of  the  placenta  in  the  first  instance  is  generally  at  its 
lower  part  and  the  blood  then  easily  trickles  down  between  the  chorion  and  the 
deciduas  and  finds  its  way  out  through  the  vulvar  orifice.  In  the  concealed 
variety  the  detachment  may  take  place  at  the  center  of  the  placenta,  its  con- 
nection around  the  entire  periphery  being  at  first  perfect.  In  this  case  there 
would  be  formed  a  large  clot  behind  the  placenta.  Or  the  separation  may 
take  place  at  the  top  of  the  placenta,  in  which  case,  as  well  as  in  the  last, 
the  hemorrhage  would  be  to  a  certain  extent  limited.  Then,  again,  the  mem- 
branes may  have  ruptured  and  the  orifice  of  escape  may  be  blocked  by  the 
*  "American  Journal  of  Obstetrics,"  vol.   xliv,   1900. 


ANOMALIES  AND  DISEASES  OF  THE  PLACENTA. 


225 


presenting   part    or   by  some  of   the    appendages  of   the    fetus  or   by  a   large 
blood-clot. 

Among  the  predisposing  causey  are  profound  anemia,  general  ill  health  with 
great  debility,  persistent  pelvic  congestion  from  any  cause,  prolonged  gesta- 
tion, multiparity,  and  the  loose  attachment  of  the  placenta  which  is  normal 
in  the  last  two  months  of  gestation  and  depends  upon  the  fatty  changes  going 
on  as  preparatory  to  labor.  Thus,  we  rarely  see  accidental  hemorrhage  until 
the  last  few  weeks  or  at  the  onset  of  labor,  and  seldom  in  primigravidae.  It 
is  questionable  whether  this  hemorrhage  can  ever  occur  with  a  healthy  pla- 
centa and  uterus;  some  dis- 
eased condition,  as  syphilis, 
uterine  or  peri-uterine  inflam- 
mation, or  nephritis,  is  neces- 
sary as  a  predisposing  cause. 
The  observations  of  many 
point  to  a  close  connection 
between  nephritis  and  this 
hemorrhage,  the  apoplexies 
and  degenerative  changes  of 
the  decidua  and  placenta 
favoring  the  hemorrhage.* 

The  most  important  cause 
of  this  complication  is  disease 
of  the  deciduae. 

Among  the  exciting  causes 
is  traumatism  ;0f  various 
kinds,  direct  and  indirect,  re- 
ceived either  externally  or 
from  violent  muscular  efforts 
on  the  part  of  the  patient. 
This  cause  cannot  be  denied, 
although  it  is  ignored  by  some 
authorities.  Underbill  reports 
a  case  due  to  direct  trauma- 
tism, and  I  observed  a  case  in 
which  a  woman  pregnant  at 
the  eighth  month,  while  hang- 
ing clothes  from  the  fire- 
escape  of  a  tenement-house, 
leaned  heavily  with  her  ab- 
domen against  the  iron  rail- 
ing. Faintness  and  profuse 
uterine  hemorrhage  occurred 

immediately,  followed  shortly  by  labor  and  the  delivery  of  a  dead  fetus  and 
several  large  blood-clots.     The  placenta  was  situated  above  the  lower  segment. 

Hemorrhage  from  traumatism  does  not  always  follow  the  shock.  In  a 
case  of  mine  it  was  delayed  several  days.  This  is  in  accordance  with  the 
observations  of  Kiwisch,  who  states  that  hours  or  days  may  elapse  between 
the  two  events.  Again,  hemorrhage  may  occur  when  the  patient  is  in  repose 
or  even  when  she  is  asleep.  This  accident  has  also  followed  indirect  trauma- 
tism, as  slipping  on  ice,  lifting  heavy  weights,  vomiting,  coughing,  concussion, 

*  O.  Von  Weis:  "Archiv  f.  Gynak.,"  Bd.  xlvi,  H.  2,  1893. 
15 


Fig.  272. — Internal  Concealed  Hemorrhage  from 
Entire  Separation  of  a  Normally  Situated  Pla- 
centa. Internal  Concealed  "Accidental"  Hem- 
orrhage.— {Modified  from  Winter.) 


226  PATHOLOGICAL  PREGNANCY. 

jolting,  etc.,  by  which  probably  some  of  the  placental  attachments  were  lacer- 
ated. Profound  emotion  has  been  given  as  an  exciting  cause  by  Barnes,*  by 
causing  sudden  alteration  in  the  equilibrium  of  the  utero-placental  circulation. 
A  marked  predisposition  is  undoubtedly  present  in  these  cases.  A  very  short 
cord  has  sometimes  proved  to  be  the  cause  of  this  accident,  especially  if  the 
fetus  be  vigorous.  In  hydramnios,  in  which  the  volume  of  the  uterus  is 
quickly  diminished  by  the  escape  of  a  large  bulk  of  liquid;  or  in  twin  deliv- 
eries, after  the  birth  of  one  child,  the  subsequent  contraction  may  cause 
placental  detachment  with  fatal  hemorrhage.  Sligh's  case  t  illustrates  both 
of  these  conditions,  as  well  as  the  necessity  for  instantaneous  action  in  com- 
plications of  this  kind. 

Certain  cases  have  been  reported  in  which  the  uterus  was  abnormal;  in  one 
case  there  was  present  vagina  duplex,  and  the  uterus  also  shared  in  the  abnor- 
mality. Other  cases  have  shown  a  condition  of  uterus  bicornis  with  one 
horn  rudimentary.  If  the  placenta  is  attached  to  the  latter,  and  should 
this  horn  contract  while  the  rest  of  the  uterus  remains  passive,  the  placenta 
may  become  prematurely  separated.  That  this  phenomenon  does  take  place 
has  been  clearly  proved. 

Symptoms  and  Diagnosis. — In  the  external  form,  the  escape  of  blood 
is  noticed,  and  at  once  points  to  the  existing  condition.  The  problem  in  the 
case  of  the  concealed  variety  is  often  obscure.  In  certain  cases  marginal 
separation  does  not  occur,  and  the  escaping  blood  is  collected  between  the 
uterus  and  placenta,  where  it  forms  clots  which  are  retained  in  this  situation 
(Fig.  279).  More  commonly,  however,  separation  of  the  placental  margin 
does  occur,  and  there  forms  a  collection  of  blood  between  the  wall  of  the  uterus 
and  the  membranes.  This  may  be  either  in  the  region  of  the  fundus  or  near 
the  cervix.  In  the  latter  situation  the  blood  may  be  prevented  from  escaping 
by  the  pressure  of  the  presenting  fetal  part.  In  this  case  the  coagula  are 
prone  to  cause  much  pain  from  the  distention  and  stretching  of  the  uterine 
muscle.  Besides  the  appearance  of  blood  in  the  frank  variety,  there  is  generally 
pain,  which  is  at  times  persistent  and  of  a  tearing,  piercing  character  or 
cramp-like,  colicky,  and  bearing-down.  The  suffering  varies  greatly  in  dif- 
ferent cases.  Pain  may  be  localized  at  the  placental  region  or  at  the  lower 
uterine  segment,  due  to  stretching  from  retained  clots.  Instead  of  a  sudden 
gush  of  blood,  there  may  be  a  more"  or  less  continuous  dripping,  part  escaping 
and  part  coagulating.     This  condition  may  continue  for  weeks. 

The  symptoms  of  the  concealed  form  are  chiefly  extreme  collapse  and  ex- 
haustion with  no  apparent  cause.  In  case  of  extreme  internal  hemorrhage 
with  slight  external  escape,  the  diagnosis  may  be  made  by  the  fact  that  the 
constitutional  symptoms  are  so  much  more  severe  than  the  amount  of  blood 
visible  would  be  likely  to  account  for.  Shock  may  exist  even  when  there  is 
no  great  loss  of  blood;  it  is  then  due  to  enormous  distention  of  the  uterus. 
Besides  the  pain  already  referred  to,  which  may  be  agonizing,  there  may 
be  observed  an  irregularity  in  the  form  of  the  uterus,  caused  by  the  massed 
coagula.  This  is  not  easy  to  make  out,  except,  perhaps,  in  the  case  of  a  patient 
who  is  thin  and  who  has  very  lax  abdominal  walls.  A  rapid  increase  in  the 
size  of  the  uterus  may  be  noticed.  There  miay  be  a  complete  absence  of  labor 
pains,  and  if  they  are  present  they  are  usually  slight  and  insufficient.  Escape 
of  blood-serum  by  the  vagina  is  a  symptom  of  great  significance  as  indicating 
the  persistence  of  clots  within  the  uterus. 

Differential   Diagnosis. — Placenta  prcevia    can  be  differentiated    from  acci- 
*  "System  of  Obstetrics."  page  582.  f  "American  Journal  of  Obstetrics,"  1S92. 


ANOMALIES  AND   DISEASES  OF  THE  PLACENTA.  227 

dental  hemorrhage  only  by  actually  palpating  the  placenta  in  the  former, 
although  the  latter  condition  is  apt  to  occur  in  the  first  stage  of  labor,  to  be 
attended  by  sharp  pains,  and  to.  persist  until  the  uterus  is  evacuated  or  the 
patient  dies.  No  deviations- from  the  conditions  of  normal  pregnancy  are 
revealed  by  vaginal  examination  in  accidental  hemorrhage.  This  statement 
must  be  slightly  modified,  as  in  the  concealed  variety  vaginal  examination 
may  show  a  prominence  of  the  vaginal  part  of  the  uterus.  It  is  as  if  it  were 
being  pressed  down  into  the  vagina  from  above,  while  the  presenting  part  is 
often  well  above  the  pelvic  brim.  Rupture  of  the  uterus  follows  a  protracted 
or  obstructed  labor  or  operation.  There  are  previous  thinning  of  the  lower 
uterine  segment  shown  above  the  pubis,  recession  of  the  presenting  part,  and 
diminution  of  the  uterine  tumor;  the  membranes  have  usually  ruptured;  escape 
of  the  fetus  into  the  abdominal  cavity  may  be  observed,  giving  two  abdominal 
tumors.  It  is  easy  to  exclude  lacerations  of  the  cervix  by  palpation  and 
inspection.  A  ruptured  extrauterine  pregnancy  must  also  be  taken  into  con- 
sideration. The  history  of  the  case  should  be  investigated.  Abnormal  pains, 
changes  in  the  fetal  heart  sounds,  alterations  in  the  outlines  of  the  uterus, 
symptoms  of  the  hemorrhage,  and  the  condition  of  the  vaginal  part  of  the 
uterus  afford  the  chief  differential  points. 

Prognosis. — When  there  is  an  external  flow  of  blood,  the  prognosis  for  the 
mother  is  not  very  unfavorable,  since  the  condition  may  be  readily  recognized 
and  treated.  Speedy  termination  of  pregnancy  will  check  the  bleeding  and 
save  the  patient's  life.  The  shock  is  not  so  great,  for  the  uterus  is  not  so  dis- 
tended; and  the  separation  of  the  placenta  is  frequently  incomplete.  About 
85  per  cent,  of  the  children  are  born  dead.  In  the  concealed  form,  however, 
there  is  far  more  danger,  and  here  the  mortality  is  great,  for  often  the  diagnosis 
is  not  made  until  the  patient  is  nearly  moribund.  Of  Goodell's  106  cases, 
54  mothers  died — 51   per  cent. 

Other  factors  influencing  this  great  mortality  are  the  constitution  of  the 
patient,  which  is  generally  feeble  and  diseased,  and  the  shock  from  overdis- 
tention.  The  very  fact,  too,  of  overdistention  indicates  loss  of  contractility 
of  the  uterine  musculature.  The  nearer  the  completion  of  the  second  stage, 
and  the  more  readily  the  cervix  is  dilated  naturally  or  artificially,  the 
better  the  outlook.  In  pregnancy  the  chances  for  fetus  and  mother  are  better 
in  multiparas  than  in  primiparae,  on  account  of  the  ease  with  which  the  os  can 
be  dilated  in  the  former. 

For  the  child,  the  prognosis  is  even  worse.  Of  107  children,  of  Goodell's 
cases,  6  only  were  born  alive — 94  per  cent,  mortality.  This  is  probably  ex- 
plained by  the  fact  that  when  blood  collects  between  the  placenta  and  the  uterus, 
the  fetal  part  of  the  former  is  probably  torn  and  the  child  dies  from  hemor- 
rhage. Other  causes  of  fetal  death  are  prematurity  and  asphyxiation  from 
interference  with  the  function  of  the  placenta.  The  maternal  mortality 
in  Holmes's  series  of  cases  is  considerably  lower  than  that  commonly  admitted — 
32.2  percent.;  his  child  mortality  (85.8  per  cent.)  is  slightly  better  than  that  here- 
tofore taught.  The  death-rates  (maternal)  for  concealed  and  open  hemorrhages 
were  23  and  34.6  per  cent,  respectively.  It  is  difficult  to  formulate  special 
prognostic  indications. 

Treatment. — If  the  hemorrhage  takes  place  during  pregnancy  and  is  not 
severe,  the  treatment  should  be  parallel  with  that  of  threatened  miscarriage. 
Or,  even  if  the  hemorrhage  has  been  large  but  has  entirely  ceased,  the  uterus 
need  not  be  interfered  with.     The  treatment  should  then  be  preventive  and 


228  PATHOLOGICAL  PREGNANCY. 

protective.     These  patients-^  should  always  be  carefully  watched.     It  may  be 
that  a  living  child  will  be  bom  at  term. 

In  the  presence  of  severe  hemorrhage  the  two  indications  are  (i)  to  secure 
tonic  and  continuous  uterine  contraction  and  (2)  the  emptying  of  the  uterus 
as  rapidly  as  is  consistent  with  the  safety  of  the  mother.  I  believe  the  first 
indication  is  most  surely  obtained  by  (i)  artificial  rupture  of  the  membranes,  (2) 
massage  and  manual  compression  of  the  uterus,  and  (3)  the  repeated  hypo- 
dermatic injections  of  ergot  (ttvxxx  of  the  tincture  every  fifteen  minutes  for 
three  or  four  doses).  The  speedy  delivery  can  be  accomplished  by  rapid  instru- 
mental and  digital  dilatation  of  the  cervix  and  the  use  of  forceps,  version,  or 
perforation  according  to  indication.  Deep  incisions  of  the  cervix  are  occa- 
tionally  useful. 

The  most  efficient  check  to  hemorrhage  is  uterine  contraction,  which  must 
be  brought  about  if  possible.  By  rupture  of  the  membranes,  the  liquor  amnii 
will  escape  and  the  uterine  contraction  will  take  place.  If  the  loss  of  blood  is 
very  small,  it  may  be  that  rupture  of  the  membranes  will  be  the  only  artificial 
step  necessary,  and  the  rest  will  be  looked  after  by  nature,  though  early  rupture 
of  the  membranes  delays  labor.  In  severe  cases  the  mother's  safety  alone 
should  be  considered,  for  the  death  of  the  child  is  reasonably  certain. 

In  the  milder  forms,  vaginal  plugging,  massaging  the  uterus,  with  general 
stimulation,  should  be  used  till  the  cervix  is  sufficiently  dilated  to  allow  of 
delivery.  Tampons  must  not  be  used  after  rupture  of  the  membranes,  but  the 
method  of  tightly  tamponing  the  vagina  when  the  membranes  are  intact,  as  prac- 
tised at  the  Dublin  Rotunda,  has  given  good  results.  A  modified  Champetier  de 
Ribes  bag  under  the  same  conditions  can  be  tried  until  dilatation  is  obtained. 
A  firm  abdominal  binder  should  be  applied  to  prevent  any  internal  collection 
of  blood  from  forming.  Uterine  compression  and  the  administration  of  ergot 
will  further  contractions,  as  will  the  application  of  an  ice-bag  over  the  sus- 
pected place  of  hemorrhage.  Cold  may  be  applied  by  atomizing  ether  over 
the  abdomen.  If  the  hemorrhage  does  not  cease,  or  if  concealed  hemorrhage 
is  suspected,  the  uterus  must  be  emptied.  During  the  progress  of  labor  and 
delivery  the  uterus  should  be  carefully  followed  down  by  an  assistant,  and 
after  delivery  every  effort  should  be  made  to  secure  and  maintain  uterine  con- 
traction.    (See  Expression  of  Fetus,  Part  X.) 

Perforation  may  be  indicated  if  the  child  is  dead  or  non-viable,  or  if  the  fetal 
head  is  large  or  the  maternal  pelvis  very  small,  or  the  hemorrhage  so  severe 
as  to  endanger  the  mother's  life.  Cassarean  section  should  be  considered  in  ex- 
treme cases.  If  the  patient  is  in  collapse,  it  may  be  best  to  revive  her  by 
warmth  and  stimulants  before  operative  proceedings  are  begun.  The  after- 
treatment  consists  in  the  prevention,  if  possible,  of  post-partum  hemorrhage. 
When  much  blood  has  been  lost,  the  resulting  anemia  must  be  promptly 
treated  by  hypodermoclysis  of  decinormal  saline  solution,  with  rectal  and  intra- 
venous injection  as  well.  There  have  been  no  recent  advances  made  in  the 
therapeutics  of  this  affection,  which  is  still  unsatisfactory. 

3.  Stasis,  Passive  Congestion,  and  CEdema. — Obstruction  of  the  return  cir- 
culation of  the  placenta  gives  rise  to  a  characteristic  state  of  that  organ. 
Through  the  resulting  oedematous  saturation,  the  size  of  the  latter  may  undergo 
a  fourfold  increase.  It  becomes  pale  and  friable,  and  hence  easily  disintegrated 
during  expulsion,  with  retention  of  certain  portions.  As  in  the  case  of  oedema 
elsewhere,  stasis  may  not  be  the  sole  efficient  cause,  for  a  hydremic  quality  of 
the  blood  incidental  to  the  underlying  state  of  the  patient  may  co-operate. 
Stasis  and  oedema  of  the  placenta  have  been  encountered  in  cardiac  disease 


ANOMALIES  AND   DISEASES   OF   THE  PLACENTA. 


229 


(so-called  cardiac  placenta),  renal  disease,  and  other  maternal  conditions. 
More  commonly,  however,  the  causes  are  to  be  sought  in  hydramnios  or  some 
obstruction  in  the  circulation  -of  -the  fetus.  The  latter  class  includes  syphilitic 
obstruction  of  the  umbilical  vein  (Fig.  277),  and  disease  of  the  fetal  heart,  liver, 
and  kidneys.  Finally,  in  general  fetal  anasarca  the  placenta  may  be  oedematous. 
When  the  fetus  is  responsible  for  the  oedema,  the  fetal  portion  of  the  placenta 
is  chiefly  involved. 

4.  Interstitial  Hemorrhage  (Apoplexy,  Infarction,  Hematoma,  Thrombosis). — 
The  effusion  of  blood  is  not  necessarily  interstitial,  for  it  may  be  between  the 
chorion  and  placenta,  in  the  form  of  a  large  clot,  over  the  whole  external 
chorionic  surface;  or  it  may  represent  a  utero-placental  hemorrhage  (Fig.  279), 
The  first  occurs  during  the  first  three  months  of  pregnancy,  before  complete  union 
of  the  chorion  and  decidua;  after  the  third  month,  this  union  prevents  effusion 
beyond  the  limits  of  the  placenta. 
Hence  during  the  greater  portion  of 
pregnancy  the  hemorrhage  is  apo- 
plectic and  sharp!}'  distinguishable 
from  accidental  and  inevitable  pla- 
cental hemorrhages  (Figs.  273,  274, 
275,  and  276). 

Pathology. — It  is  in  the  early 
months  that  hemorrhage  more  com- 
monly occurs  from  true  apoplexy, 
which  consists  in  the  rupture  of  the 
fragile  maternal  capillaries  surround- 
ing the  villi.  Later  on  in  pregnane}', 
the  cause  is  more  often  thrombosis  in 
the  sinuses,  or  rupture  of  the  fine 
blood-vessels  which  enter  the  placen- 
tal sinuses  after  penetrating  the  upper 
layer  of  the  decidua  serotina.  These 
masses  of  coagulated  blood,  in  their 
several  stages  of  degeneration,  con- 
stitute placental  hematomata.  These 
formations  undergo  the  usual  retro- 
gressive metamorphoses.  (i)  The 
form  of  the  fresh  clot  is  most  com- 
mon when  abortion  has  resulted  from 
the    hemorrhage.      (2)    The    extrav- 

asated  blood  may  be  walled  ofE  by  a  fibrous  envelope,  more  or  less  thick, 
and  may  consist  of  reddish  or  brownish  liquid,  or  even  clear  serum,  while  the 
blood  coloring-matter  is  collected  upon  the  cyst-wall  or  the  neighboring  villi. 
(3)  The  liquid  may  contain  numerous  white  blood-corpuscles,  giving  it  the 
appearance  of  pus,  and  such  collections  have  been  described  as  "placental 
abscesses"  by  various  writers.  (4)  In  other  cases  the  fibrin  element  may  be 
in  the  ascendency.  This  condition  is  found  particularly  in  certain  cases  of 
thrombosis  of  the  placental  sinuses ;  as  in  an  aneurysm  in  the  course  of  obliteration 
the  slow  coagulation  of  blood  results  in  the  deposition  of  layers  of  fibrin.  (5) 
The  serum  may  rapidly  disappear,  leaving  the  red  blood-corpuscles  in  a  mass, 
while  the  leucocytes  are  either  distributed  through  the  latter  or  collected  in 
one  place.  (6)  Still  another  change  is  the  organization  of  the  clot,  by  which 
a  distinct  neoplasm  is  formed,  while  the  adjacent  villi  go  through  a  fibro-fatty 


Fig.  273. — Hemorrhages  into  the  Pla- 
centa Caused  by  Albuminuria. — {Ribe- 
mont-Lepage.) 


230 


PATHOLOGICAL  PREGNANCY. 


degeneration.  The  utero-placental  hemorrhage  may  be  recognized,  after  the 
expulsion  of  the  ovum,  by  the  characteristic  appearance  of  the  latter.  It  is 
fleshy  in  consistency,  dark  bluish-black  in  color,  and  has  a  very  smooth  sur- 
face. On  examination  the  amnion  and  chorion  are  found  to  be  uninjured.  The 
fetus  may  be  absorbed,  if  sufficient  time  has  elapsed  between  its  death  and  the 
expulsion  of  the  ovum.  If  the  period  of  time  is  shorter,  the  fetus  will  be  seen 
floating  in  the  liquor  amnii.  If,  as  the  ovum  is  discharged,  the  decidua  becomes 
detached,  the  former  looks  much  like  a  blood-clot.  It  is  to  the  hemorrhage  into 
the  placental  site,  after  the  third  or  fourth  month,  that  Cruveilhier  has  applied 
the  term  placental  apoplexy.     If  the  extravasation  of  blood  takes  place  into  the' 


Fig.  274. — Early  Placental  Infarct  showing  Coagulation  Necrosis  of  Villi  and 
Portions  of  Blood-vessels.  The  Dark  Homogeneous  Areas  are  Necrotic. 
X  35. — {From  a  specimen  in  the  Pathological  Laboratory  of  the  Cornell  University  Medi- 
cal College.) 

I.  Group  of  villi  completely  necrotic,  fibrinoid  homogeneous,  staining  deeply  with  eosin; 
2.  large  vessels,  the  peripheral  portions  of  whose  walls  are  fibrinoid  and  necrotic. 


uterine  sinuses,  thrombosis  of  the  placental  sinuses  is  said  to  have  taken  place 
(Slavjansky). 

Etiology. — The  blood-current  in  the  sinuses  of  the  placenta  moves  very  slowly 
in  its  course;  this  sluggishness,  with  the  predominance  of  fibrin  in  the  blood  of 
pregnant  women,  causes  a  tendency  to  thrombosis.  The  placental  villi  may  be 
diseased.  The  heart  from  some  cause  may  be  stimulated  to  sudden  and  excessive 
action,  which  produces  apoplexy  not  only  of  the  placenta,  but  also  of  the  brain. 
Syncope  also  gives  rise  to  a  tendency  to  thrombosis.  The  more  common  locality 
of  the  rupture  is  in  the  maternal  part  of  the  placenta ;  its  cause  is  some  patho- 
logical condition  of  the  mother  which  leads  to  great  arterial  tension  and  venous 
congestion;  e.  g.,  chronic  nephritis.     In  this  state  any  additional  strain  on  the 


ANOMALIES  AND   DISEASES   OF  THE   PLACENTA. 


231 


already  overtaxed  venous  walls  makes  them  rupture,  with  the  consequent  apo- 
plexy or  extravasation.  Traumatism  also  may  produce  this  condition;  for  ex- 
ample, a  blow  upon  the  abdomen.  If  the  cause  be  of  fetal  origin,  death  may 
result  from  the  arrested  blood-supply. 

Symptoms. — There  are  no  clinical  symptoms  characteristic  of  this  condition. 
The  condition  terminates  in  abortion.  When  the  discharged  ovum  is  examined, 
the  cause  will  be  apparent. 

Prognosis. — The  danger  increases  with  the  advance  of  pregnancy,  and  in 
the  latter  months  it  is  considerable. 

Treatment. — The  treatment  is  that  of  abortion  and  premature  labor. 

5.  Placentitis. — To-day  it  is  admitted  that  inflammation  of  the  placenta 
may  occur,  even  if  very  infrequently.  The  best  argument  for  the  existence 
of  placentitis  as  a  disease  is  the  great 

number  of  progressive  and  retrogres-  ^-.-—-^ 

sive  lesions,  encountered  in  the  organ, 
which  are  known  to  follow  inflamma- 
tion in  other  portions  of  the  body.  The 
principal  objection  to  the  recognition 


Fig.   275. — Fresh    Hemorrhagic    Infarct 
OF  THE  Placenta. — {Schilling.) 


Fig.  276. — Placental  Infarct  in  Eclamp- 
sia. Subamniotic  Necrotic  Area. — 
(Schaeffer.) 


of  the  existence  of  placental  inflammation  lies  in  the  absence  of  capillaries  and 
nerves  in  the  maternal  portion.  Placentitis  may  be  divided  into  acute  and 
chronic  forms,  (i)  Acute  septic  placentitis:  This  affection  is  mentioned  by 
authors  as  having  been  caused  by  direct  infection  either  from  attempts  at 
criminal  abortion  or  from  rupture  of  a  pyosalpinx  into  the  uterus.  Pus 
forms  in  situ,  and  with  the  phenomena  of  general  sepsis,  abortion  results. 
(2)  Gonorrheal  placentitis:  According  to  Donat,  the  gonococcus  is  able  to 
cause  an  acute  purulent  inflammation  which  extends  from  the  decidua  sero- 
tina  into  the  fetal  placenta  and  produces  interruption  of  pregnancy".  Von 
Franque  is  skeptical  as  to  the  existence  of  this  type  of  disease.  (3)  Eman- 
uel's disease:  This  author  has  described  a  necrotic  and  purulent  inflammation 
of   the  placenta  in  the  lesions  of   which  he  found  certain  non-specific  micro- 


232 


PATHOLOGICAL  PREGNANCY. 


organisms.  The  affection  first  involved  the  decidua  and  thence  extended  into  the 
maternal  placenta,  causing  abortion.  In  this  connection  it  may  be  stated 
that  placentas  which  exhibit  many  of  the  phenomena  that  commonly  follow 
acute  inflammation  elsewhere  (white  infarcts,  necrotic  foci,  thrombosis,  etc.) 
may  well  have  been  aft'ected  by  some  form  of  bacillary  disease.  (4)  Specific 
placentitis:  Authors  speak  by  implication  of  placental  alterations  in  the  acute 
specific  infectious  diseases.  We  have  been  unable  to  obtain  any  satisfactory 
account  of  these  lesions.  (5)  Interstitial  placentitis:  This  condition,  which 
doubtless  corresponds  to  the  decidual  and  diffuse  placentitis  of  some  authors, 
is  an  interstitial  inflammation  of  the  maternal  portion  of  the  placenta  which 
begins  in  the  vascular  trabeculse.  Through  the  changes  which  accompany 
chronic  inflammation  in  general,  the  villi  are  subjected  to  compression  and 
arrest   of  blood-supply.     Secondary   degenerative   changes   then   ensue  in  the 

parenchyma  of  the  organ,  which  becomes 
diminished  in  size.  Firm  adhesions  may 
form  between  the  placenta  and  the  wall  of 
the  uterus.  Endometritis,  either  primary 
or  secondary,  is  doubtless  the  cause  of  a 
majority  of  these  affections.  Hegar  and 
Maier  once  described  a  form  of  interstitial 
placentitis  which  was  essentially  a  peri- 
arteritis. (6)  Renal  or  albmninuric  pla- 
centitis: There  are  no  constant  changes  in 
the  placentce  of  women  who  are  suffering 
from  albuminuria,  but  such  individuals 
very  commonly  exhibit  such  alterations  as 
whits  infarcts,  round-cell  infiltration,  var- 
ious degenerations,  hemorrhages,  fibrous 
hypertrophy  of  villi,  endarteritis  and  peri- 
arteritis, etc.  These  lesions  in  turn  cause 
defective  development  or  death  of  the  fetus, 
premature  delivery,  premature  separation 
of  a  normally  seated  placenta,  and,  much 
more  rarely,  adhesions.  All  these  changes 
may  occur  without  nephritis,  the  latter 
being  only  a  contributory  cause,  acting 
perhaps  indirectly  through  the  presence  of 
endometritis  of  renal  origin. 
6.  Infectious  Granulomata. — The  placental  changes  in  tuberculosis  and 
syphilis  are  tolerably  well  known. 

(i)  Tuberctdosis. — LocaHzation  of  this  affection  in  the  placenta  is  extremely 
rare,  and  is  known  to  occur  only  under  the  following  conditions :  In  acute  miliary 
tuberculosis,  as  well  as  in  the  chronic  form  of  the  same  disease  which  follows  pul- 
monary phthisis,  we  sometimes  encounter  small  grayish-yellow  tubercles  in  the 
organ.  They  are  but  sparsely  present.  The  placenta  is  almost  immune  to  attack 
from  Koch's  bacillus.  The  tubercles,  which  are  usually  caseous,  are  scattered 
in  the  intervillous  space — decidua,  villi,  stroma,  etc.  The  blood-vessels  of  the 
villi  exhibit  obliteration  as  a  result  of  endothelial  proliferation.  In  this  manner 
the  fetus  might  be  protected  to  a  certain  extent  from  placental  infection.  The 
diagnosis  of  tuberculosis  of  the  placenta  has  been  verified  by  the  demonstration 
of  the  bacillus  and  also  by  animal  experiment. 

(2)  Syphilis. — This  affection  is  perhaps  the  most  prolific  cause  of  death 


Fig.  277. — Syphilitic  Placental  Vil- 
li. Marked  proliferation  of  the  con- 
nective-tissue and  rotind-cell  infiltra- 
tion (5),  especially  in  the  neighbor- 
hood of  the  thickened  blood-vessels 
(i) ;  a  few  of  the  villi  have  lost  their 
protoplasmic  investment  and  are  in 
process  of  conversion  into  intervillous 

1  thrombi  (3) ;  6,  normal  protoplasm 
containing  nuclei;  7,  villous  blood- 
vessels— healthy,  belonging  to  the 
fetus — (original  microscopic  draw- 
ing) . — (Scheie  ffer.) 


ANOMALIES  AND  DISEASES  OF  THE  PLACENTA.  233 

of  the  fetus.  The  syphiUtic  placenta  is  larger,  thicker,  and  lighter  in  color 
than  normal.  Its  appearance  suggests  that  it  has  been  soaked  in  water 
While  the  normal  placenta  is.  from  one-sixth  to  one-eighth  the  weight  of  the 
child,  the  syphilitic  placenta-  weighs  about  one-third  or  one-fourth  as  much 
as  the  child.  The  fact  must  of  course  be  considered  that  the  syphilitic  child 
is  less  developed;  syphilitic  fetuses  being  generally  smaller  than  normal.  Macro- 
scopically  these  placentae  may  differ  in  appearance.  If  the  fetus  has  been  dead 
some  time,  the  placenta  will  be  very  pale  in  color,  soft  or  slippery,  and  greasy 
to  the  touch.  If  the  child  lives  till  term,  the  organ  is  commonly  unusually 
large  and  pinkish  in  color,  due  to  the  hypertrophied  decidua,  which  hides  the 
true  color.  Normal  villi  possess  only  a  few  cells  but  many  blood-vessels;  the 
syphilitic  villi  are  filled  with  round  cells  which  have  undergone  fatty  degenera- 
tion and  resemble  embryonic  cells.  In  syphilitic  villi  the  blood-vessels  are 
scarce;  the  stroma  is  increased,  and  is  represented  by  granulation  tissue;  the 
blood-vessels  show  endarteritis,  and  in  hardened  specimens  the  villi  are  seen  to 
be  thickened.  Parts  of  healthy  tissue  of  the  placenta,  which  intervene  between 
the  diseased  areas,  may  exhibit  extravasations.  However,  these  character- 
istics do  not  give  absolute  proof,  but  probability,  of  syphilis.  Corroboration 
may  be  furnished  from  the  condition  of  the  child.  When  gummata  are  found 
as  in  cases  in  which  maternal  syphilis  antedates  conception,  they  vary  in  size 
from  a  hempseed  to  an  olive,  and  possess  the  characteristic  structure  of  gum- 
mata in  other  situations.  These  formations  have  a  central  core  of  soft  yel- 
lowish or  reddish  cheesy  degeneration,  surrounded  by  concentric  lamellae,  or 
a  true  abscess  cavity,  with  fatty  walls  which  secrete  pus.  They  often  undergo 
fatty  and  calcareous  changes.  Diagnosis:  It  is  impossible  to  make  an  accurate 
diagnosis  during  pregnancy.  Prognosis:  The  fetus  generally  dies  rapidly  of 
malnutrition,  owing  to  obliteration  of  the  nourishing  blood-vessels.  Placental 
syphilis  is  one  of  the  commonest  causes  of  abortion.  The  greatest  maternal 
risk  occurs  at  the  time  of  labor,  from  adherent  placenta  and  subsequent  sepsis. 
The  treatment  of  fetal  syphilis  will  generally  be  prophylactic.  If  both  parents 
of  the  future  embryo  be  affected  with  the  disease,  then  antisyphilitic  treat- 
ment should  be  instituted  in  both  individuals.  If  only  one  be  syphilitic,  it 
would  be  useless  to  treat  the  healthy  one. 

7.  Secondary  Alterations  in  the  Placenta. — Under  the  head  of  secondary 
progressive  alterations  we  shall  consider  hyperplastic  and  sclerotic  changes, 
together  with  adherent  placenta.  Degenerations  comprise  the  results _of  fetal 
death,  white  infarction,  cystic,  fatty  and  calcareous  degeneration,  etc. 

(i)  Hyperplastic  and  Sclerotic  Changes. — Proliferation  of  fixed  connective- 
tissue  cells  with  an  immediate  tendency  to  hyperplasia  and  an  ultimate  dis- 
position toward  sclerotic  and  atrophic  metamorphosis  is  a  sequel  to  a  number 
of  primary  placental  affections.  These  changes  are  due  in  most  cases  to 
chronic  placentitis,  whether  the  latter  be  owing  to  simple  endometritis,  renal 
disease,  or  syphilis.  Fibrous  metamorphosis  has  received  various  terms: 
viz.-,  interstitial  placentitis;  sclerosis  of  the  placenta;  scirrhous,  tuberculous, 
or  cartilaginous  degeneration,  etc.  Of  special  clinical  interest  are  the  adhesions 
which  form  as  a  result  of  the  organization  of  hyperplastic  tissue  between  the 
placenta  and  the  uterine  wall;  and  the  white  infarcts,  so  called,  which  are  due  in 
part  to  the  constriction  of  certain  areas  of  placental  tissue  by  the  same  sclerotic 
process. 

(2)  Adhesions. — Adhesions  between  the  placenta  and  the  uterine  wall  are  of 
rare  occurrence,  for  the  majority  of  cases  thus  characterized  are  only  instances 
of  simple  retention.     True  adhesion,  however,  occurs  at  times,  and  the  two 


234  PATHOLOGICAL  PREGNANCY. 

structures  are  then  consolidated  to  such  a  degree  that  any  natural  separation 
is  impossible.  Adhesions  may  also  be  the  result  of  imperfect  development  (ab- 
sence of  glandular  zone,  of  entire  serotina,  etc.;  see  Part  II),  through  which  the 
villi  become  deeply  imbedded  in  the  muscular  wall  of  the  uterus.      (See  Part  V.) 

(3)  Degenerations  which  Follow  Fetal  Death. — After  death  of  the  fetus 
in  utero  the  circulation  persists  for  a  while  in  the  intervillous  space,  the 
placental  tissue  remaining  intact.  The  fetal  vessels  gradually  become  oblit- 
erated by  endothelial  proliferation.  The  stroma  becomes  changed  into  fibroid 
tissue.  The  fixed  connective-tissue  cells  of  the  pedicles  of  the  villi,  chorion, 
and  amnion  begin  to  proliferate,  with  resulting  thickening  of  these  structures. 
Langhans's  layer  and  the  syncytium  also  show  irregular  proliferation.  In 
the  course  of  time  the  syncytium  disappears,  and  the  villi  become  transformed 
into  a  hyaline  substance  devoid  of  nuclei.  The  circulation  in  the  intervillous 
space  ceases  as  a  result  of  thrombosis.  Fatty  degeneration,  calcification, 
and  other  degenerative  processes  are  in  evidence.  The  placenta  as  a  whole 
undergoes  marked  shriveling,  becoming  small,  thin,  and  of  a  hardness  sug- 
gesting leather  or  cartilage.     Upon  section  it  is  white  and  almost  homogeneous. 

(4)  White  Infarcts. — White  infarcts  constitute  graAdsh-red,  yellowish,  or 
pure  white  areas  of  the  placenta  which  replace  the  spong}^,  highly  vascular 
tissue  of  the  latter.  At  first  only  moderately  firm,  they  increase  in  hardness 
progressively  from  the  deposition  of  lime-salts.  In  certain  cases,  however, 
there  is  a  secondary  softening  of  the  infarcts,  which  may  terminate  in  cyst 
formation.  Microscopic  infarcts  occur  in  all  placenta  and  fully  50  per  cent, 
of  the  latter  exhibit  infarcts  which  are  visible  to  the  naked  eye;  hence  these 
small  formations  are  physiological.  But  infarcts  of  considerable  size,  also, 
are  frequently  encoxuitered.  The  large  or  pathological  infarcts,  some  of  which 
may  involve  half  the  placenta,  have  a  various  extent  and  distribution.  They 
may  be  scattered  here  and  there  as  rounded  or  stellate  areas  without  any  regular 
arrangement,  and  are  then  termed  insular.  Wedge-shaped  infarcts  have 
their  bases  in  the  serotina  and  their  apices  among  the  masses  of  villi.  Annular 
infarcts  are  sometimes  seen,  and  may  involve  the  free  border  of  the  placenta 
or  be  seated  within  the  peripher^^  Finally,  there  is  a  type  of  infarcts  known 
from  its  location  as  the  subchorial.  The  nature  and  pathology  of  white  infarcts 
have  given  rise  to  much  discussion.  The  simplest  and  most  plausible  expla- 
nation is  as  follows:  In  the  hyperplastic  and  sclerotic  changes  which  have 
just  been  described,  beginning  as  an  endarteritis  in  the  chorionic  villi,  com- 
pression of  placental  tissue  must  necessarily  occur  at  times  in  certain  areas 
which  ultimately  have  their  blood-supply  cut  off  and  undergo  the  transforma- 
tion known  as  coagulation-necrosis.  This  lifeless  tissue  becomes  changed 
to  a  homogeneous  mass  of  hyaline  appearance,  which  undergoes  various  retro- 
grade changes,  such  as  softening,  canalization  (so-called  canalized  fibrin), 
cyst  formation,  calcification,  etc.  Secondary  hemorrhages  may  occur  about 
these  infarcts.  As  these  formations  are  deprived  of  blood-vessels,  the  area 
of  the  normal  placental  tissue  is  diminished  to  a  greater  or  less  extent,  so  that 
the  nutrition  of  the  fetus  may  suffer,  even  to  the  extent  of  abortion.  The 
danger  to  the  mother  lies  in  the  possibility  of  the  formation  of  adhesions  between 
the  infarcts  and  the  uterine  wall,  with  resulting  irregular  detachment  and  reten- 
tion of  the  placenta. 

Williams*  examined  500  consecutive  placenta  for  infarcts,  including 
both  white  and  red  varieties.  He  found  185  of  these  specimens  free  from 
all  appearance  of  such  lesions  except  to   an   almost   microscopic    degree.      But 

*  Prof.  Welch's  Festschrift,  1900. 


ANOMALIES  AND   DISEASES  OF  THE  PLACENTA. 


235 


15  were  the  seat  of  the  red  or  hemorrhagic  variety.  The  remaining  300 
placentae  all  contained  white  infarcts,  distributed  as  follows:  on  the  surface, 
223,  or  44.6  per  cent.;  purely  marginal  location,  77,  or  15.4  per  cent.  As 
implied  above,  microscopic  infarcts  are  invariably  present.  The  mere  act 
of  infarct  formation  is  physiological,  and,  at  best,  a  normal  senile  degeneration  of 
the  placenta.  When  present  in  a  high  degree,  it  is  the  result  of  some  disease,  and 
more  especially  albuminuria,  in  the  mother.  We  are  quite  unable  to  explain  the 
pathogeny  of  morbid  infarct  formation,  but  it  seems  certain  that  bacteria  play 
no  part  therein.  The  inherent  independence  of  albuminuria  and  eclampsia  is 
shown  by  the  fact  that  we  do  not  necessarily  find  high  degrees  of  infarction  in 
the  latter  disease. 

(5)  Cystic  Degeneration. — The  great  majority  of  placental  cysts  result  from 
softening.     In  some  cases  the  latter 

process  is  primary  and  results  from 
liquefaction  of  the  original  myxo- 
matous tissue  of  the  placenta.  There 
is  some  analogy  between  these  for- 
mations and  vesicular  moles.  The 
largest  and  most  familiar  placental 
cysts,  however,  result  from  the 
softening  of  infarcts.  These  may 
attain  such  dimensions  as  to  simu- 
late a  second  bag  of  waters.  This 
type  of  cyst  is  largely  subchorional 
in  location.  The  cystic  fluid  is  usu- 
ally cloudy  and  contains  albumin. 
Placental  cysts  may  rupture  during 
labor  (Fig.  278). 

(6)  Calcareo^is  Degeneration. — 
This  is  by  no  means  uncommon;  as 
a  rule,  it  is  not  of  clinical  import- 
ance, and  lime  concretions  are  some- 
times found  in  large  numbers.  Its 
occurrence  in  syphilis  has  already 
been  mentioned.  Placental  calculi, 
ossiform  concretions,  placental  ossi- 
fication, stone  placenta,  have  already 
been  noted  under  the  subject  of  in- 
farcts. These  deposits  are  almost 
always  found  on  the  uterine  placen- 
tal surface,  in  the  decidua  serotina, 

whence  they  may  extend  to  the  fetal  part  of  the  placenta.  When  the  degener- 
ation begins  in  the  fetal  structures,  it  is  confined  to  them,  and  implicates  the 
small  blood-vessels  of  the  villi,  extending  from  their  tiny  extremities  to  their 
trunks.  These  concretions  are  in  the  form  of  grains,  needles,  or  scales.  They 
consist  of  amorphous  carbonates  and  phosphates  of  lime  and  magnesia ;  as 
many  as  five  hundred  have  been  found  in  one  placenta  (Chambord).  Stony 
scales  or  laminse  or  even  larger  formations  may  be  found  in  placentae  that 
have  been  left  in  titero  weeks  or  months  after  the  occurrence  of  fetal  death. 
In  the  common  form,  during  the  life  of  the  fetus,  the  placental  function  is  not 
disturbed. 

(7)  Fatty  Degeneration. — This  frequently  occurs,  and  modern  investigation 


Fig.  27S. — Multiple  Cysts  on  the  Fetal 
Surface  of  the  Placenta. — {Ribentoni- 
Lepage.) 


236 


PATHOLOGICAL  PREGNANCY. 


tends  to  show  that  fatty  change  is  usually  consecutive  to  the  fibrous  metamor- 
phosis (Robin-Ercolani).  It  sometimes  occurs  in  the  decidua  serotina.  Here, 
however,  it  is  part  of  a  chronic  endometritis,  the  placenta  being  involved 
secondarily  (interstitial  endometritis  of  Hegar).  A  fibrous  change  may  occur 
in  the  vilH  themselves,  or  in  the  interspaces;  the  usual  contraction,  obliteration 
of  vessels,  and  fatty  change  following.  This  fatty  tissue  is  friable  and  greasy  to 
the  touch.  It  greases  any  substance  with  which  it  comes  in  contact,  and  is 
rather  firm  in  consistency. 

(8)  Miscellaneous  Degenerations. — So-called  hyaline  degeneration  is  a  pheno- 
menon which  accompanies  white  infarction.  Pigment  deposits  consist  of  hemo- 
globin or  its  derivatives  and  result  from  extravasations  of  blood.  They  are 
usually  small  and  disseminate,  and  are  devoid  of  pathological  significance. 
Mucous  degeneration  such  as  attacks  the  chorionic  villi  may  occur  at  times  in 
the  placenta. 

8.  Placental  Tumors. — (i)  Placentomata:  Excluding  cysts,  which  are  prob- 
ably better  regarded  as  an  expres- 
sion of  degenerative  change,  and 
vesicular  moles  and  deciduoma  ma- 
lignum  which  belong  to  the  pathol- 
ogy of  the  deciduse,  a  number  of 
placental  neoplasms — about  fifty  in 


Fig.  279. — Separation  of  the  Placenta  by  a  Retro-placental  Hemorrhage.     The 
figure  to  the  right  is  the  blood-clot  removed  from  the  center  of  the  placenta. — (Tarnier.) 


round  numbers — have  been  placed  upon  record,  all  of  which  appear  to  be  of  the 
same  fundamental  type.  The  favorite  locality  is  the  fetal  surface  of  the  placenta 
near  the  cord.  Much  more  rarely  they  occur  upon  the  maternal  surface  or  in 
the  substance  of  the  organ.  They  are  of  a  firmer  texture  than  the  placenta,  from 
which  their  outlines  and  color  are  well  defined,  and  are  also  isolated  from  the 
placental  tissues  proper  by  a  well-marked  capsule.  Histologically  these  tumors 
are  examples  of  myxoma  fibrosum,  although  some  authors  prefer  the  name  an- 
gioma, because  of  the  great  number  of  blood-vessels  present.  In  a  few  cases  of 
placental  tumor  the  structure  of  sarcoma  was  approximated.  None  of  the 
reported  cases  had  any  tendency  to  malignancy.  Coagulation-necrosis  often 
develops  in  these  tumors.  (2)  Placental  Polypi:  These  formations  are  not 
usually  included  under  placental  tumors  proper,  as  they  represent  a  disease 


ANOMALIES  OF  THE    UMBILICAL  CORD.  237 

of  the  uterine  cavity  which  was  due  originally  to  the  persistence  of  placental 
residues.  They  may,  however,  be  described  in  this  connection.  Placental 
polypi  may  be  benign  or  malignant.  The  formation  of  the  former  has  been 
described  by  Pilliet  as  follows :  The  fragments  that  are  left  behind  after  abortion 
may  either  assume  new  growth,  by  drawing  their  nourishment  from  the  uterine 
vessels,  or  they  may  have  deposited  on  them  blood-clots,  which  become 
organized  and  constitute  large  polypoid  tumors.  These  tumors  give  origin 
to  abundant  hemorrhages,  muco-sanguinolent  leucorrhea  which  is  commonly 
very  offensive,  together  with  attacks  of  uterine  colic.  The  uterus  is  boggy 
in  consistency,  large,  and  subinvoluted.  Treatment  should  include  thorough 
uterine  curettage.  The  malignant  or  destructive  placental  polyp  consists  of 
a  malignant  growth  of  one  villus  or  of  several  villi,  which  are  apt  to  penetrate 
the  uterine  walls,  even  as  far  as  the  abdominal  cavity.  Death  follows  from 
exhaustion,  hemorrhage,  or  peritonitis. 


V.  ANOMALIES  OF  THE  UMBILICAL  CORD. 

/.  Length.  2.  Thickness,  j.  Insertion.  4.  Coils.  5.  Knots.  6.  Tangling.  7.  Torsion. 
8.  Stenosis  of  the  Vessels,  p.  Cysts.  10.  Calcareous  Deposits.  11.  Hernia.  12.  Syphilis. 
ij.  Obstruction  of  the  Vessels.  14.  Dilatation  of  the  Umbilical  Vein.  15.  Hyper- 
trophy of  the  Valves.       16.  Congenital  Tumors. 

1.  Length. — The  cord  at  term  is  usually  about  twenty  inches  (50  cm.)  in 
length;  but  great  variations  occur.  It  is  sometimes  almost  absent,  and  cases 
have  been  recorded  in  which  it  was  four  or  five  feet  (122  to  152  cm.)  in  length. 
There  is  one  case  recorded  in  which  the  cord  attained  the  length  of  nine 
feet  (2.75  m.);  others  in  which  it  was  only  two-fifths  of  an  inch  (i  cm.)  long. 
Deviations  from  the  normal  length  are  sometimes  of  clinical  importance. 
(See  Pathological  Labor,  Part  V.)  Abnormal  shortness  may  come  from  natural 
or  artificial  causes;  as,  for  instance,  when  adhesive  inflammations  of  the 
amnion  result  in  the  gluing  together  of  the  coils  of  the  cord,  or  when  the  latter 
become  attached  to  the  fetal  skin  or  to  the  amnion.  When  it  is  ^tremely 
short,  it  prevents  the  descent  of  the  fetus,  or  causes  hemorrhage  from  premature 
placental  separation,  or  even  mal-presentation.  When  very  long,  it  may  form 
dangerous  coils  or  knots  (Fig.  280). 

2.  Thickness. — The  cord  may  develop  to  the  thickness  of  the  adult  thumb. 
In  this  case  the  vessels  are  normal,  there  being  simply  an  increase  in  the  density 
of  the  tissue  of  the  cord  (Figs.  288  to  290). 

3.  Insertion. — This  may  be  central,  lateral  (battledore),  or  velamentous 
(Figs.  248  to  263).  In  the  latter  case  the  vessels  of  the  cord  pass  between  the 
membranes,  for  a  greater  or  less  distance,  before  reaching  the  placenta.  This 
is  due  to  the  fact  that  during  the  development  of  the  cord  adhesions  form 
between  the  cord  and  either  the  amnion  or  the  chorion,  thus  interfering 
with  the  formation  of  the  sheath,  which  normally  binds  them  together. 
The  eccentric  position  is  by  far  the  most  frequent.  Hyrtl's  table  includes 
many  abnormal  placentae,  and  is,  therefore,  not  absolutely  correct.  It  is  as 
follows:  Eccentric,  54  per  cent.;  central,  16  per  cent.;  marginal,  19  per  cent.; 
velamentous,  11  per  cent.  The  last  percentage  is  too  great,  as  it  is  usually 
only  2  or  3  per  cent.  The  velamentous  cord  is  important  from  a  practical 
standpoint,  for  rupture  of  the  membranes  may  cause  a  rupture  of  the  cord 
and  the  death  of  the  fetus  from  hemorrhage.     This  form  of  insertion  is  a  source 


238 


PATHOLOGICAL  PREGNANCY. 


of  considerable  danger  to  the  fetus,  for  the  vessels,  in  their  abnormal  position, 
are  exposed  to  traumatism,  and  their  rupture  may  result  in  serious  or  even 
fatal  hemorrhage,  before  the  delivery  of  the  fetus  can  be  brought  about.  There 
is  an  analogous  condition  in  that  form  called  meso-cord,  from  its  resemblance 
to  the  suspensory  structures  of  the  kidney,  rectum,  or  colon.  Here  the  cord, 
instead  of  having  its  normal  insertion,  is  received  into  an  amniotic  fold  which  it 
first  traverses.  The  well-being  of  the  fetus  is  not  at  all  interfered  with  by  this 
anomaly. 

4.  Coils. — The  cord  frequently  becomes  wound  around  the  fetus.  I  had  a 
case  in  my  own  practice,  in  which  the  cord  was  coiled  seven  times  around  the 
child's  neck,  the  result  being  the  death  of  the  fetus  (Fig.  288).  Another  case  is 
recorded,  in  which  it  was  in  nine  coils  about  the  neck.     In  2200  labors  I  found 

the  cord  about  the  neck  in  514  cases,  or  23.36  per 
cent.  The  cord  was  coiled  once  about  the  neck  in 
19.77  P6^  cent.;  twice  in  3.18  per  cent.;  three  times 
in  0.40  per  cent.  Coiling  was  called  by  the  earlier 
writers  "suicidium  foetus  in  utero"  (Figs.  283  to  287). 
5.  Knots  (Figs.  288  to  290). — These  form  in  con- 
sequence of  the  fetal  movements ;  the  fetus  may  pass 
through  a  loop  in  the  cord,  thus  producing  a  knot; 


Fig.  280. — Short  Umbilical 
Cord. 


Fig.  281. — Tangling  of  the  Umbilical  Cords  in  a  Case 
OP  Twins  Contained  in  One  Amniotic  Cavity,  a,  Com- 
plicated knot  of  both  umbilical  cords;  A,  the  same  knot 
enlarged. — (Ahlfeld.) 


these  are  of  the  most  varied  appearance.  They  are  also  due,  at  times,  to  uterine 
contractions  during  labor,  before  rupture  of  the  membranes,  and  form  a  possible 
complication  of  version.  Knots  are  usually  harmless,  since  the  constrictions 
are  rarely  tight  enough  completely  to  obliterate  the  lumen  of  the  vessels.  The 
pulsations  of  the  cord  favor  the  loosening  of  the  knots,  on  account  of  the  in- 
cessant repetition  of  the  shock  of  pulsation.  Rarely  a  true  knot  forms;  false 
knots  are  the  result  of  local  increase  of  Wharton's  jelly  (Figs.  291  and  290).  The 
obstruction  of  the  umbilical  vessels  causes  a  more  or  less  complete  arrest  of  the 
circulation,  which  decidedly  hinders  the  development  of  the  fetus  and  may 
even  cause  its  death. 

6.  Tangling. — In  multiple   pregnancies   the   cords   sometimes   become  tan- 


ANOMALIES  OF -THE    UMBILICAL  CORD. 


239 


gled,  and  this  accident  results  nearly  always  in  asphyxiation  of  both  fetuses, 

with  their  expulsion  (Figs.  281  and  282). 

7.  Torsion. — This    is   a   twisting  of   the   cord  on   its  long  axis.     It   occurs 

most  commonly  about  the  seventh 
month.  It  was  formerly  supposed  to 
be  due  to  active  movements  on  the 
part  of  the  fetus,  but  it  has  recently 
been  shown  that,  while  a  certain 
amount  of  torsion  may  be  produced 
by  fetal  movements,  it  is  never  cap- 
able of  occluding  the  vessels,  and  that 
the  higher  degrees  of  torsion  occur 
after  the  death  of  the  fetus  (Schauta), 


Fig.  282. — Coiling  of  Both  Umbilical  Cords 
OF  Twins,  about  Each  Other  and  about 
A  Leg.  Also  Two  True  Knots. — (Winc- 
kel.) 


Fig.  283. — Coiling  of  the  Umbilical 
Cord  about  the  Fetus  and  Its  Ex- 
tremities.—  (McGtll-i  cuddy.) 


Fig.    284.  —  Coil 
iNG  about  a  Leg. 


Fig.  285.  —  Coiling 
about  a  Leg  and 
AN  .\rm. 


Fig.  286.  —  Coil- 
ing about  the 
Neck  and  Leg. 


Fig.  287.  —  Coil- 
ing about  a 
Shoulder. 


and  as  a  result  of  the  movements  of  the  mother.  Torsion  occurs  more  frequently 
in  the  case  of  male  children,  in  multiparas,  and  with  long  cords.  It  usually  occurs 
near  the  umbilicus,  and  the  cord  is  frequently  oedematous  and  the  seat  of  thrombi 


240 


PATHOLOGICAL  PREGNANCY. 


and  cysts.     A  certain  amount  of  twisting  of  the  arteries  around  the   vein  is 
generally  seen,  commonly  ten  to  twelve  twists. 

8.  Stenosis  of  the  Vessels. — The  umbilical  vein  is  sometimes  narrowed  by 
a  local  periphlebitis.  This  occurs  at  the  placental  insertion  and  usually  does 
no  harm.  Thrombi  sometimes  form  in  the  umbilical  arteries,  as  the  result 
of  atheromatous  changes,  and  partially  occlude  the  vessels.  If  these  pro- 
cesses are  extensive,  corresponding  injury  to  the  fetus  of  course  results.  This 
stenosis  may  be  congenital.  If  the  involvement  concerns  only  the  vein, 
hypertrophy  follows,  with  congestion  and  oedema  of  the  placenta.  If,  however, 
the  arteries  are  also  affected,  the  circulation  of  the  fetus  will  be  obstructed 
and  the  fetus  will  become  oedematous. 

9.  Cysts. — Serous  and  mucous  cysts  are  sometimes  found  in  the  cord.  This 
may  result  froni  cystic  degeneration  which  follows  some  obstruction    to  its 

circulation,  and  as  a  result  a  collection  of  serum 
formed  in  the  spaces  beneath  the  amniotic  cover- 
ing and  in  the  tissues  of  the  allantois.  Possibly 
it  is  a  result  of  the  liquefaction  of  Wharton's  jelly, 


Fig.  288. — Coiling  of  the  Um- 
bilical Cord  Seven  Times 

ABOUT    THE     NeCK     OF    THE 

Fetus.  Death  op  the 
Fetus  and  Miscarriage. — 
(Author's  case.) 


Fig.  289. — Syphilis  of  the  Umbilical  Cord.  Transverse 
section  showing  inflammatory  changes  of  the  media  and 
adventitia.  i.  Vein  with  thin  wall;  2,  thickened  artery; 
3,  rotmd-ceU  infiltration;  4,  stroma  of  normal  myxoma- 
tous connective  tissue;  5,  external  layer  of  cuboidal  cells 
investing  the  umbiHcal  cord. — (Schaeffer.) 


the  fluid  collecting  in  the  sacs  that  are  formed ;  it  may  follow  apoplexies  of  the 
cord.     It  is  not  clinically  important. 

10.  Calcareous  deposits  are  sometimes  seen,  and  are  supposed  to  be  the 
result  of  syphilis.  They  are  found  in  the  mucous  tissue  or  in  the  blood-vessels, 
but  are  of  no  importance. 

11.  Hernia. — This  is  the  protrusion  of  some  of  the  abdominal  contents  at 
the  umbilicus,  the  result  of  faulty  development.  The  intestines,  in  the  fetus, 
are  at  first  outside  the  abdominal  cavity,  and  in  case  of  hernia  they  have  "either 
failed  to  enter  the  abdomen,  or,  having  entered,  they  are  permitted  to  escape 
through  a  defect  in  the  abdominal  wall.  In  some  cases  nearly  all  the  abdominal 
viscera  escape.  Sometimes  the  traction  exerted  by  the  escaped  viscera  pro- 
duces deformities  of  other  fetal  parts,  such  as  strictures  of  the  rectum,  or  de- 
formities of  the  legs.  The  dilated  sheath  of  the  cord  envelops  the  protruded 
viscera.     Often  the  infant  is  still-bom.     If  the  child  is  bom  alive,  the  displaced 


ANOMALIES  OF  THE    UMBILICAL  CORD. 


241 


organs  must  be  protected  by  proper  bandages  till  operation  can  be  performed. 
This  affection  is  really  eventration  rather  than  hernia. 

12.  Syphilitic  Lesions. — Macroscopic  lesions  are  induration  of  the  cord, 
thickening  of  the  vascular  coats,  disconnection  of  the  funicular  vessels,  owing 
to  the  disappearance  of  mucous  tissue.  Histological  lesions  are  endophlebitis 
and  periphlebitis,  endarteritis  and  periarteritis  (Fig.  291). 

13.  Obstruction  of  the  Vessels. — The  disconnection  of  the  funicular  vessels, 
by  the  disappearance  of  mucous  tissue  (Wharton's  jelly),  is  a  very  rare  condi- 
tion; it  is  known  to  have  been  due  to  syphilis,  and  is  accompanied  by  vascular 

lesions,  such  as  gumma  of  the 
external  coat  of  the  vein,  endo- 
phlebitis and  periphlebitis. 
^^  ^j  14.  Dilatation  of  the  Umbili- 

cal Vein. — The  vein  may  be  the 
seat  of  abnormal  dilatations,  of 


Fig.  290. — True  Knot  of  the  Umbilical  Cord. 
The  true  knot  is  the  center  of  the  three  in  the 
left-hand  figure,  the  ones  above  and  below  are 
false  knots.  The  right-hand  figure  is  the  same 
cord  with  the  knot  untied. — (Author's  case.) 


Fig.  291. — ^False  Knot  of  the  Um- 
bilical Cord. 


varicosities  perhaps  as  large  as  a 
pigeon's  egg,  and  injurious  to 
the  development  of  the  fetus,  on 
account  of  the  embarrassment  to  the  circulation.  This  condition,  however,  is 
generally  unimportant,  though  sometimes  one  of  the  varicose  veins  will  rupture. 
As  a  rule,  this  takes  place  close  to  the  placenta,  and  a  large  hematoma  is  formed 
At  times  the  hemorrhage  is  so  extensive  as  to  cause  fetal  death. 

15.  Hypertrophy  of  the  Valves. — This  also  rarely  occurs.  The  etiology  is 
probably  syphilis;  the  lumen  of  the  vessel  is  obstructed,  and  the  situation  of 
the  valves  may  be  indicated  by  large  nodules. 

16.  Congenital  Tumors. — Congenital  tumors  of  the  umbilicus  are  of  very 
infrequent  occurrence.  They  comprise  atheromata  and  dermoids  and  so-called 
entero-teratomata.     Atheromata   and  dervioids:  In    1892    Pernice   was   able   to 

10 


242  PATHOLOGICAL  PREGNANCY. 

find  reports  of  but  three  cases  of  these  tumors  in  literature.*  He  describes 
these  formations  as  benign  epithelial  tumors.  Pernice  believes  that  dermoids 
alone  originate  in  the  scar  of  the  cord  because  the  latter  should  contain  no  seba- 
ceous glands.  Atheromata  doubtless  originate  in  the  skin  around  the  umbilical 
scar.  It  is  quite  likely  that  the  dermoid  alone  is  congenital.  Enter o-teratomata: 
These  growths,  also  known  as  adenomata,  bear  a  marked  resemblance  to  ordinary 
granulomata. 


ANTENATAL  PATHOLOGY. 

Embryonal  and  Fetal  Pathology  in  General. — Ballantyne  and  others  make  a 
sharp  distinction  between  fetal  and  embryonal  pathology.  During  the  period 
of  embryonal  life,  which  is  computed  by  various  authors  at  from  six  to  twelve 
weeks,  what  is  known  as  organogenesis  occurs.  In  other  words,  the  future 
organs  of  the  body  are  rapidly  differentiated  from  the  primordial  embryonal 
tissue,  so  that  at  the  termination  of  this  cycle  they  have  attained  almost  com- 
plete development.  During  the  remainder  of  intrauterine  existence  there  is 
little  more  than  an  increase  in  size,  just  as  in  extrauterine  life.  It  seems  most 
natural  to  suppose  that  disease  in  the  embryo  must  be  manifested  rather  by 
arrested  or  perverted  development  of  organs  than  by  ordinary  pathological 
alterations.  A  slight  malformation  of  an  embryonal  organ  must  increase  in 
size  with  the  growth  of  the  latter;  in  no  other  way  could  the  occurrence  of  ex- 
tensive malformations  be  explained.  But  there  is  a  close  association  between 
deformities  and  diseases ;  this  causes  the  surmise  that  certain  conditions  which 
appear  to  be  diseases  of  the  fetal  period  have  in  reality  an  earlier  or  embryonal 
origin,  and  are  themselves,  therefore,  malformations.  On  the  other  hand,  a 
few  true  deformities  may  arise  during  the  fetal  period  because  organogenesis, 
while  nearly  completed  in  the  earlier  weeks  of  gestation,  goes  on,  to  a  certain 
extent,  throughout  intrauterine  life,  and,  indeed,  through  many  years  of  indi- 
vidual existence.  Those  structures  in^  which  complete  development  is  delayed 
include  the  bones,  teeth,  genitals,  etc.  The  pathology  of  the  embryonal  period, 
then,  is  currently  believed  to  be  co-equal  with  the  subject  of  teratology,  or  mon- 
strosities, including  malformations.  We  are  still  deeply  ignorant  as  to  the  manner 
in  which  such  conditions  are  produced.  Studies  of  very  early  embryos  which 
have  perished  either  from  intrinsic  causes  or  from  affections  of  the  membranes 
throw  hardly  any  light  on  the  genesis  of  monstrosities.  There  can  be  little 
doubt  that  abnormal  development  of  the  amnion,  with  or  without  the  forma- 
tion of  adhesions  and  constricting  bands,  would  work  havoc  with  the  embryo 
and  probably  the  fetus  as  well,  but  the  solution  of  the  problem  is  hardly 
advanced  by  this  theory.  On  account  of  the  absence  of  facts  in  regard  to 
teratogeny,  I  have  omitted  this  subject,  and  after  a  statement  of  the  little  that 
is  known  of  embryonal  pathology,  and  illustrations  of  most  of  the  (i)  monstrosi- 
ties, I  shall  consider  (2)  the  diseases  of  the  fetal  period  of  intrauterine  life,  and 
(3)  death  of  the  fetus. 

Pathology  of  the  Early  Human  Embryo. — Professor  Mall,  of  Johns  Hopkins 
University, t  has  examined  over  fifty  pathological  embryos  at  very  early 
stages  of  development.  He  states  that  after  the  second  week  pathological  con- 
ditions are  readily  recognizable.  Diseases  of  the  very  young  ovum  are  of  two 
kinds:  primarily  embryonal  and  primarily  chorial.  In  the  first  group  the 
*  "Die  Nabelgeschwulste,"  Halle  a.  S.  t  Professor  Welch's  Festschrift,  1900. 


ANTENATAL  PATHOLOGY.  243 

embryo  is  affected  while  the  development  of  the  chorion  is  unchanged.  In  the 
second  group  the  chorionic  disease  results  in  the  strangulation  of  the  embryo. 
Roughly  speaking,  these  affections-  may  be  represented  pathologically  as  con- 
sisting in  three  degrees:  viz.,"(i)  simple  arrest  of  development,  (2)  partial 
destruction  of  embryo,  (3)  total  destruction  of  the  same.  About  twenty-three 
cases  studied  by  Mall  were  examples  of  arrested  development,  while  in  five 
the  embryo  was  partly,  and  in  eight  completely,  destroyed.  Eight  cases  were 
also  noted  in  which  the  disease  appeared  to  originate  in  the  umbilical  vesicle. 
It  would  appear  that  in  the  majority  of  cases  the  pathological  process  began 
in  the  embryo.  The  chorion  is  endowed  with  great  vitality  and  is  able  to 
exist  independently  and  undergo  normal  development  for  a  considerable  time 
after  the  death  of  the  embryo,  but  finally  its  independent  existence  comes  to  a 
standstill,  and  it  either  persists  as  a  cystic  formation  or  collapses  to  form  a 
fleshy  mole.  On  the  other  hand,  the  embryo  undergoes  rapid  destruction  if 
the  chorion  becomes  affected.  In  computing  the  period  at  which  abortions 
occur  we  must  naturally  be  guided  by  the  degree  of  development  of  the  chorion, 
not  by  that  of  the  embryo.  In  simple  arrest  of  development  we  may  note  the 
coincidence,  for  example,  of  a  two  weeks'  embryo  in  a  four  weeks'  ovum. 


VI.  DEFORMITIES  AND  MONSTROSITIES  OF  THE  FETUS. 

CLASSIFICATION* 


(A)  SINGLE 
MONSTERS 

(IncludiriK 
I  ncidental 
M  onste  rs 
or  Anomal- 
ous Indi- 
viduals). 


(B)  DOU- 
BLE MON- 
STERS. 


Heterotaxy.     Splanchnic  Inversion. 

Complete. 

ncomplete.  Androgynoides.     Gynandroides. 


.  Hermaphro- 

DISM. 


Anomalous 
Individuals. 


Essential 
Monstrosi- 
ties. 


I.  Separate 
Twins. 


II.  United 
Twins. 


Hemiterata.    (Anomalies  of : 


/(i)  Growth. 

(2)  Non-union. 

/(3)  Cleavage. 
J(4)  Structure. 
'(5)  Persistence. 


({a 
1      i 


)     Excess.        (4) 
Defect. 

/Subdivided  accord] 
(     ing  to  locality. 

f  (a)  Redundancy. 
I     [b)  Defect. 

Microscopic. 


(a)    Intrinsic. 
Extrinsic. 


I.  Terato- 

MELUS. 


I  2.  Teratocor- 

MUS. 


|3.  Teratoce- 
phalus. 


4.  Teratopro- 

SOPUS. 


Non-disappearance 
of  fetal  structures 

,,,   ^     r  .•       ,    f  (a)    Intrinsic.      {b) 

(6)  Conformation.!  <^   '  ^  ' 

f(a)  Hemimelus. 

(  \b)  Phocomelus,  etc. 

{a)  Dipus. 

(b)  Monopus. 

(c)  Apus. 

Celocormus. 
f  (a)  Teratothorus. 
( {b)  Teratosoma. 


(i)  Ectromelus. 

{2)  Symelus. 

I  (i)  Complete. 
[  (2)  Partial. 


( (a)  Iniencephalus. 

(i)  Involving  spine-;  (d)  Exencephalus. 

((c)   Anencephalus. 


(2)  Local. 

(1)  Aprosopus. 

(2)  Paraprosopus. 


Homologous  Normal  Twins. 


.  Omphalo- 
sites. 


Paracephalus. 

Acephalus. 
Amorphus. 


I.  Dicephalus 
(epischistos). 


.  Dipygus 
(hyposchistos). 


\3.  Amphischistos. 


I.  Helerotypus. 


\2.  Heteralius. 


\3.  Endocynia. 


f  fa)  Hemicephalus. 
\  [b)   Encephalocele. 


,  Schistoprosopus. 
J  Ectroprosopus. 
j  Cyclopia. 
^  Synotia. 


1.  Anceps. 

2.  Dipus. 

3.  Apus. 

4.  Acormus. 

Thorus,  Athorus,  Acormus. 

f  Mylacephalus. 
1  Anideus. 


(i)  Sympygus. 


(2)  Monopygus. 


(i)  Syncephalus. 


f  Lecanopagus. 
J  Ischiopagus. 
j  Pygopagus. 
^Somatopagus. 


fMonolecanus. 
J^  Monosomus  (dipro- 
sopus). 


Craniopagus. 

Hemipagus. 

Janiceps. 


,   ,   ,,  ,    ,         f(a)  Dibrachius. 

(2)  Monocephalus.  1^^^'  Deradelphus. 

({a)  Sternopagus. 
(i)  Thoracopagus.  <  (6)  Xiphopagus, 
(     etc. 

(2)   Rachipagus. 

(a)  Thoracopagus  parasiticus. 

(b)  Dicephalus  parasiticus. 
ic)   Acephalus. 

(d)  Athorus. 

(e)  Apygus. 

(a)  Craniopagus  parasiticus. 
lb)   Ischiopagus  parasiticus. 

(c)  Dipygus    parasiticus    or    polymelus 
(nolomelus,  pygomelus,  etc.). 

({a)   Polygnathus  (epiguathus,  etc.). 
<  (b)  Sacrococcygeal  tumors. 
((c)   Fetal  inclusion. 


j  Tricephalus. 


(C)  TRIPLE 
MONSTERS 

The  illustrations  of  deformities   and    monstrosities  are  taken  mostly  from   Ahlfeld's  Atlas.    A  few  are  from 
Hirst  and  Piersol's  Atlas  and  from  photographs  and  drawings  of  the  author's  cases. 

244 


50ME  OF  THE  MONSTROSITIES  AND  DEFORMITIES 
OF  THE  FETUS  INCLUDINO  SIMPLE  ANOMALIES 
A.  SINGLE  MONSTERS 


INCIDENTAL 
I.HETEROTAXY 


'■■;•■  <+ 


COMPLETE  TRANSPOSITION  OF  VISCERA 
FIG.   292 


Minovici  and  Juvara:  "Archives  des  Sciences  Medicales,"  iii,  1898 

245 


FXTERNAL  MAI  F  GENITALS  SIMULATING  FEMALE  ORGANS 

mAl  thiJMAL  iv^t  ^^'^^^  ilMUL^^i  UN^ur  t^^^  EXTERNAL  FEMALE  GENITALS  SIMULATING  MALE  ORGANS 


2    HERMAPHRODISM 
EXTERNAL 


FIG,  29S 

INTERNAL 


FIG.   296 


FIG.    297 


COMPLETE  ( BILATERAL ) 

HERMAPHRODISM 

FIG    298 


UTERUS  MASnnjNOS 
FIG".    SOO 

5.HEiMITERATA 


FIG.    299  HERMAPHRODISM 


FIG/    SOI 


( 1 )  ANOMALIES  OF  GROWTH 


OVERGROWTH  OF  FFNGERS 
FIG.   802 


OVERGROWTH  OF  ONE  HALF  OF  TONGUE 
FIG    SOS 


OVERGROA/VTH  OF  HAND    DEFECT  OF  RADIUS 
FIG.  ?S04  FIG.   311 


OVERGROWTH  OF  FEET 
Fia    SOS 


OVERGROWTH  OF  LEG 
FIG    a06 


OVERGROWTH  OF  ONE  HALF  OF  FACE 
FIGJ  S07 
DEFECT  OF  HIP  JOINT 
FKJJ  ais 


L_ 


L'46 


(2) ANOMALIES  OFNON  UNION 


DOUBLE  HARELIP 
FIO.  316 


SINGLE  HARELIP 
FIG.    814 


PERSISTENT 

HARELIP  AND  CLEFT  PALATE         BRANaiL^^  CLEF.X 
FIG.  81S 


TRACHEAL  FISTULA 
FIG.   818 


BUCCAL  FISTULA 

FIG.    317  CONGENITAL  UMBILICAL  HEBNLA. 

FIO.    820 


SPLIT  PELVIS 
FIO.  821 


H\T>OSPADIAS 
EXSTROPHY  OF  THE  BLADDER  EPISPADIAS  FIG.   824 

FIO.    822  FIG.   328 


247 


(5 )  ANOMALIES  OF  CLEAVAGE 


DOUBLE  FALLOPtAN  TUBE 
FIG.    SS9 


DOUBLE  TOUMB  DOUBLE  URETER  AND 

f-K---    S82  KIDNn- PELVIS 

FIG    338 


HORSESHOE  KIDNE\  p,Q   ■  „  ,  o 

FIG.    342 


POLYMAi^TIA 
FIG.    336 


DOUBLE   GALLBLADDER 
FIG.    337 


SUPERNUMERARY  VERTEBRAE  (TAIU 
FIC>-  840 


(6)  VICES  OF  CONFORMATION 


VULVOVAGIA"VL  ANUS 
FIG.    S4B 


ATRESIA  ANI  FT  RECTI 
FIG.  351 


ATRESIA  RECTI 
FIO.    352 


ATRESIA  ANt 
FIG     3BO 


248 


ESSENTIAL  IVIONSTERS 

1 .  TERATOMELUS   or  umb  monstrosity. 


,o6C:'\.^: 


PHOCOMELDS 
™-    333 


SIFJENOjMELUS 
FIG    356 


2  .TERATOCORMUS  or  trunk  monstrosit\'. 


PLEUROSOMA 
FIG.    361 


FISSURE  OF  DTAPHRAGIvr 
FIG.    362 


CELOSOMA 
FIG.   ye>0 


249 


5.TERATOCEPHALUS  ob  head  monstrosity 


PODENCEPHALUS 
"*    FIO.    871 


HYPERENCEPHALUS 
FIQ.  372 


EXENCEPHALUS 
FIG.    S70 


4-.TERATOPROSOPUS  or  face  monstrosity. 


FIO     SSO 


RHINOCEPHAL.US 

FIG.   379 


CEBOCEPHALUS 
FIG.    878 


OTOCEPHALUS 
FIG.    384 


(Tl'CLOCEPHAL  U  S 
FIG.    882 


250 


t^^^wjy-'"  "^ 


B.  DOUBLE   MONSTERS 

I.  SEPARATE  TWINS 

(1.  HOMOLOGOUS  NORMAL  TWINS) 

2  .  OMPHALOSITES  or  placental  parasites. 


PARACEPHALUS  DIPUS 
FIG.   386 


PARACEPHALUS  ACORMUS 
PIG.    S87 


AMORPHUS  ANIDEUS 

no.  yyi 


ACEPHALUS  ATHORUS 
FIG.   889 


MYLACEPHALUS 
FIG   890 


ACEPHALUS  THORUS 
FIG.    888 


Etymological  Key. — Prefixes:  a-  or  an-,  "absence  of";  syn-  or  sym-,  "fusion,"  or 
"blending  of  two  symmetrical  structures";  mono^,  "single,"  "undivided";  di-,  "two";  tri-, 
"three";  anti-,  "opposed"  or  "opposite";  i^ira-,  " four " ;  epi-,  "above";  hypo-,  "below"; 
ectro-,  "abortive,"  "defective,"  "rudimentary ";  5c/jz5to-,  "cleft";  micro-,  "small";  hemi-, 
"half."     Suffixes:  -pagM5,  "united,"  "connected"; -sc/iV5i05,  "cleft."     Parts  ofBody 
-cephalus,  "head";  -cormus,  "trunk";  -pygus,  "breech";  -melus,  "limb"  ("extremity") 
-thorus,  "chest"; -notos,  "back";  -prosopos,  "face";  -crania,  "skull ";  -rachis,  "spine" 
-lecanus,  "pelvis";  ischio,  "seat-bone";  -pus,  "foot,"  "leg";  -hrachius,  " arm" ;  -ophthal- 
tnos.  -opos,  "eye";  -otos,  "ear." 


251 


1 1  UNITED  TWINS 
AUTOSITES 

1.  EPISCHISTOI   (CLOVEN   ABOVE) 


MONOSOMUS  TETROPHTHALMUS 
FIG,  402 


MONOSOMUS   TRIOPHfHALMUS 
FIG.  401 


MONOSOMUS  TRIOTUS 
FIG-  4.03 


252 


2. HYPOSCHISTOI  (CLOVEN   below) 


CRANIOPAGUS    FRONTALIS 
FIG.    405 


CRANIOPAGUS  PARIETAI.IS 
FIG.    406 


CRANIOPAGUS  OCrrPITALlS 
FIG.    407 


MONOCEPHALUS  DIBRACHIUS  DIPUS 

FIG    412  _ 

MONOCEPHALUS   DIBRACHIUS  TETRAPUS M0N0CEPHALU5  DIBRACHIUS  TRIPUS 
FIG.    414  FIG.    413 


5.  AMPHISCHISTOI  (cloven  above  and  BELOW) 


3TERNOPAGUS 


^DEROTHOPAf-npAGUS 

XIPHOPAGUS  ^^'    ^'^  "^"^     ~  PROSOPOTHORACOPAGUS 

FTG.    4.1P,  THOR.\COPAGUS    TRIBRAClilUS         '^'^-    4-'^ 

FIG.    417 


253 


X)]PYGU5   CEPIIALOMELUS         J5IFYGUS  THORACOMELUS  DIPYGUS    GASTPOMELUS     DIPYGUS  Py001^rEr.US 


FIG.    426 


FIG.    428 


mo.  429 
C  TRIPLE  MONSTERS' 

TRICEPHALUS. 


EPIGNATHUS 
FIG    4SO 


fEXAL  INCLUSION 

FIG.   4S3 


SACROCOCCYGEAE  TUMOR 


254 


ANTENATAL  DISEASES  OF  THE  FETUS.  255 


VII.  ANTENATAL  DISEASES  OF  THE  FETUS. 

/,  Injections  Diseases.  2.  Acute  Poisoning,  j.  Chronic  Poisoning.  4.  Dyscrasic  Condi- 
tions. 5.  Cardiac  Diseases.  6.  Diseases  of  the  Alimentary  Tract.  7.  Diseases  oj  the 
Nervous  System.  8.  Diseases  oj  the  Urogenital  Apparatus,  g.  Skin  Diseases.  10.  Fetal 
Bone  Disease,  il.  Fetal  Traumatisms.  12.  Fetal  Neoplasms,  ij.  General  Fetal  CEdem.a. 
14.  Maternal  Traumatisms.  15.  Maternal  Uterine  Disease  Ajjecting  the  Fetus,  16. 
Fever  in  the  Mother  Ajjecting  the  Fetus.     77.  Death  oj  the  Mother  Ajjecting  the  Fetus. 

I.  Infectious  Diseases. — i.  Variola. — When  a  pregnant  woman  contracts 
this  disease,  one  of  three  conditions  may  result:  (i)  Pregnancy  is  inter- 
rupted at  the  moment  of  the  eruptive  period  and  the  woman  is  delivered  of  a 
dead  or  moribund  child  that  has  not  been  contaminated  by  the  disease.  Appar- 
ently there  has  not  been  time  for  the  latter  to  develop.  This  is  the  commonest 
termination  of  pregnancy  in  a  variolous  woman.  As  a  variety  of  the  preceding 
there  is  occasionally  noted  a  termination  in  which  the  child  survives.  This 
occurs  when  labor  sets  in  during  the  first  onset  of  the  disease  and  also  when  the 
type  of  maternal  disease  is  very  mild  (varioloid).  (2)  Pregnancy  is  not  inter- 
rupted by  the  disease.  There  is  a  simple  coincidence  of  labor  and  the  mother's 
disease  which  supervenes  shortly  before  term,  or  the  pregnancy  is  continued 
during  and  after  the  subsidence  of  the  disease  until  term  arrives.  The  children 
which  result  from  these  pregnancies  are  born  intact  and  it  is  possible  to  vaccinate 
them  successfully.  The  type  of  maternal  disease  in  this  category  must  be  very 
mild.  (3)  Pregnancy  is  interrupted  and  the  child  is  born  with  a  full  variolous 
■eruption.  These  cases  are  rare,  but  many  have  been  placed  on  record.  In  a 
few  the  eruption  did  not  appear  until  a  few  days  after  delivery.  The  most 
remarkable  of  all  cases  of  intrauterine  variola  are  seen  in  twin  pregnancies  in  which 
•one  twin  is  born  intact  while  the  other  has  variola.  Kaltenbach  has  even  reported 
a  case  of  triplets  in  which  two  of  the  children  were  born  with  smallpox  while  the 
third  was  healthy.  Vinay  regards  this  as  open  to  a  very  simple  explanation. 
A  healthy  placenta,  he  states,  does  not  allow  disease  germs  to  pass  through  it. 
When,  however,  this  organ  is  the  seat  of  infarcts  or  other  lesions,  the  natural 
"barrier  is  overcome.  (4)  To  the  preceding  categories  a  fourth  may  be  added; 
here,  while  the  mother  is  not  known  to  have  had  variola,  although  there  may  be 
a  history  of  exposure,  her  pregnancy  is  interrupted  and  the  fetus  is  found  to  have 
smallpox.  In  one  such  case  the  mother  had  had  intercourse  with  a  variolous 
convalescent  who  was  probably  the  father  of  the  child.  This  woman  was  doubt- 
less protected  from  the  disease  by  vaccination.  Vinay  is  inclined  to  believe  that 
the  maternal  immunity  in  these  latter  cases  is  more  apparent  than  real ;  for  in  all 
the  recorded  instances  of  variolous  pregnancies  in  healthy  women  the  latter  have 
•exhibited  headache  and  backache  at  the  time  when  the  fetus  should  have  been 
contracting  the  disease.  The  mother  therefore  suffers  from  the  rare  form  of  the 
latter  known  as  variola  sine  exanthema,  in  which  the  entire  eruption  may  be 
absent,  escape  observation,  or  consist  only  of  a  few  pustules.  Symptoms: 
There  is  absolutely  no  method  by  which  we  can  determine  the  incubation 
period  of  fetal  variola.  The  localization  of  the  disease  differs  considerably  from 
that  in  the  adult,  for  the  face  is  often  spared  while  the  trunk  is  likely  to  bear  the 
brunt  of  the  eruption.  The  eruption  may  be  discrete  or  confluent,  and  the 
disease  may  actually  run  its  course  in  liter o,  so  that  the  child  is  born  with  cica- 
trices only.  The  lesions  are  umbilicated,  but  do  not,  of  course,  form  crusts  in  a 
moist  medium.  When  the  fetus  is  first  attacked  in  utero,  it  betrays  its  distress 
by  violent  movement.  Prognosis:  Intrauterine  variola  is  fatal  in  the  great 
majority  of   instances.       Examples  under  which  recovery  occurs  have  already 


256  PATHOLOGICAL  PREGNANCY. 

been  cited.  The  child  is  not  necessarily  still-born,  for  it  may  survive  for 
some  days.  Surviving  children  are  sometimes  susceptible  to  vaccination,  but 
in  other  cases  are  refractory.  Treatment:  There  is  no  indication  for  thera- 
peutic abortion  and  no  management  which  can  be  directed  especially  to  the 
fetus.  All  pregnant  women  should  be  vaccinated  when  smallpox  is  prevalent. 
For  treatment  of  the  mother,  see  Section  XV. 

2.  Vaccinia. — The  child  borne  by  a  woman  who  had  smallpox  during 
her  pregnancy  may  or  may  not  be  susceptible  to  vaccination.  Those  who  are 
immune  give  no  evidence  of  having  had  fetal  variola.  Vaccinia  can  be 
transmitted  to  the  fetus.  Many  women  are  vaccinated  during  pregnancy  and 
their  infants  have  the  same  experience  soon  after  birth.  The  results  of  different 
authorities  vary  somewhat,  but,  according  to  Ballantyne,  about  33  per  cent,  of 
infants  are  in  this  way  rendered  immune.  Individual  observers  place  the  per- 
centage of  immunity  as  high  as  60  per  cent,  and  even  80  per  cent.  This  in- 
herited refractoriness  to  vaccination  is  short-lived,  so  that  such  infants  should 
by  all  means  be  vaccinated  as  soon  as  a  positive  result  is  obtainable.  The 
claim  has  been  made  that  unsuccessful  vaccination  of  the  mother  often  confers 
some  immunity  on  the  fetus. 

3.  Measles. — When  a  pregnant  woman  contracts  measles,  gestation  is 
usually  interrupted  (in  about  75  per  cent,  of  cases,  according  to  limited  figures). 
Children  thus  bom  may  present  a  morbillous  rash  and  coryza.  Ballantyne, 
who  has  seen  an  undoubted  instance  of  intrauterine  measles,  cites  some  twenty 
others  from  literature.  In  each  of  these  the  mother  herself  presented  the  symp- 
toms of  the  disease. 

4.  Scarlatina. — Pregnant  women  often  contract  this  disease,  and  may 
or  may  not  abort.  Ballantyne  has  reported  an  undoubted  case  in  which 
the  premature  infant  of  a  scarlatinous  mother  was  seen  to  have  a  rash  and  en- 
larged glands  on  the  first  day  post  partum.  According  to  this  author,  there  are 
about  a  score  of  such  cases  recorded.  Vinay  also  states  that  healthy  children 
have  been  born  of  scarlatinous  mothers  who  have  afterward  infected  the  off- 
spring by  lactation.  In  my  own  case  in  private  practice,  scarlatina  in  the 
mother  resulted,  immediately  upon  the  appearance  of  the  eruption,  in  a 
seventh-month  miscarriage  of  a  dead  fetus,  the  latter  showing  no  evidence  of 
the  disease. 

5.  Erysipelas. — The  possibility  "of  the  occurrence  of  fetal  erysipelas 
having  been  established  by  certain  obstetricians  (Kaltenbach,  Runge,  Stratz), 
Lebedjeff  succeeded  in  demonstrating  the  presence  of  Streptococcus  erysipe- 
latis  in  the  chorion.  Erysipelas  in  the  mother  is  not  often  transmitted  to  the 
fetus,  and  causes  abortion  in  about  50  per  cent,  of  all  pregnancies.  According 
to  Hofmeier,  the  fetus  exhibits  tachycardia  when  the  mother  is  attacked  by  the 
disease,  the  pulse-rate  varying  directly  with  the  mother's  temperature. 

6.  Diphtheria. — Nothing  is  known  of  intrauterine  diphtheria.  While  newly 
born  children  have  doubtless  been  contaminated  by  diphtheritic  mothers,  it  is 
doubtful  if  a  genuine  case  of  congenital  transmission  has  ever  been  recorded. 

7.  Typhoid  Fever. — Fetal  typhoid  is  a  well-established  example  of  ante- 
natal disease,  and  has  been  known  since  1840.  While  the  older  cases  were 
recognized  by  the  characteristic  intestinal  lesions,  the  fetus,  as  a  rule,  does  not 
present  this  localization.  After  the  discovery  of  Eberth's  bacillus  diagnosis 
of  fetal  typhoid  became  easier,  and  still  another  impetus  has  been  received  from 
the  Widal  reaction.  Pregnant  women  who  contract  typhoid  fever  exhibit  a 
high  percentage  of  interruption  of  pregnancy,  statistics  giving  the  frequency 
as  from    58    to    83    per    cent.    (Vinay).     The  study  of   typhoid    fetuses    since 


ANTENATAL   DISEASES   OF  THE   FETUS.  257 

the  discovery  of  Eberth's  bacillus  does  not  appear  to  show  that  the  latter 
causes  many  lesions,  although  it  is  found  very  widely  distributed.  In  other 
words,  the  fetus  is  the  seat  of  a  pure  typhoidal  sepsis  in  the  majority  of  cases 
Widal's  test  applied  to  the  "fetal  blood  has  given  positive  results,  showing 
that  the  antitoxic  as  well  as  the  toxic  principle  passes  through  the  placenta. 
Aside  from  the  occasional  occurrence  of  true  typhoid  lesions  in  the  fetus,  and 
the  common  occurrence  of  a  bacillemia  or  pure  sepsis,  it  is  believed  by  recent  ob- 
servers that  the  toxins  of  the  disease  cause  slight  but  important  structural  alter- 
ations in  the  fetal  viscera,  and  also  retard  metabolism  and  reduce  the  body- 
temperature,  so  that  the  child,  if  it  grow  up,  will  exhibit  dystrophic  stigmata, 
mental  peculiarities,  deafness,  etc.  Since  the  high  temperature  of  typhoid  is 
responsible  in  part  for  the  frequency  with  which  pregnancy  is  interrupted,  it  has 
been  supposed  that  the  Brand  method  of  treatment  would  reduce  this  rate. 
Statistics,  however,  show  very  little  improvement  in  this  respect. 

8.  Cholera. — According  to  Vinay,  this  disease  exerts  a  more  disastrous 
influence  upon  pregnancy  than  any  other,  variola  not  excepted.  Analysis  of 
many  cases  shows  53  per  cent,  of  interruptions  in  which  the  children  are  in- 
variably still-born.  According  to  Slavjansky,  the  placenta  exhibits  character- 
istic alterations,  due  in  turn  to  a  specific  metritis.  Tizzoni  and  Catani  found  the 
comma  bacillus  in  the  fetal  tissues.  The  child  is  invariably  expelled  shortly 
after  its  death,  apparently  because  of  the  oxytocic  action  of  the  cholera  virus. 
Many  mothers,  however,  must  die  undelivered.  Those  who  survive  and  whose 
pregnancies  are  not  interrupted  have  borne  healthy  children.  Ballantyne 
cites  several  instances  in  which  newly  born  infants  were  already  infected 
with  cholera,  although  Tarnier  taught  that  intrauterine  transmission  did  not 
occur. 

9.  Malaria. — The  possibility  of  fetal  paludism  has  been  extensively  ques- 
tioned, but  is  now  generally  admitted.  Children  with  enlarged  spleens  and 
other  evidences  of  paludism  have  been  born  to  malarial  mothers.  The  most 
recent  authorities  dispute  the  claim  that  plasmodium  malariae  has  ever  been 
found  in  the  fetal  tissues.  Evidence  afforded  of  intermittent  fever  in  the 
newly  born  is  open  to  criticism,  because  such  infants  may  have  been  bitten  by 
infected  mosquitos  soon  after  birth.  Practically,  therefore,  the  diagnosis  must 
be  based  upon  the  presence  of  congenital  hypertrophy  of  the  spleen,  associated 
perhaps  with  dropsical  accumulations,  extravasated  blood,  discolored  skin,  and 
pigmented  white  blood-corpuscles.  Such  children  exhibit,  in  addition,  sub- 
standard weight,  debility,  wrinkled  skin,  pallor,  etc.  It  has  been  claimed  that 
children  bom  of  malarious  mothers  exhibit  almost  constant  defects  in  length 
and  weight  in  comparison  with  those  born  of  healthy  mothers.  There  is  also  a 
very  high  percentage  of  interruptions  of  pregnancy  in  malarious  women,  though 
abortion  is  not  common.  Vinay  has  collected  notes  of  158  pregnancies  with  120 
interruptions  (about  76  per  cent.);  but  of  this  number  there  were  but  20  abor- 
tions, the  remainder  representing  premature  deliveries.  Hence,  statements 
which  relate  to  small  size  and  debility  of  the  newly  born  may  be  explained  largely 
by  prematurity.  Malaria  has,  per  se,  a  marked  tendency  to  bring  on  delivery 
ahead  of  time,  and  since  quinine  is  a  specific  for  the  disease,  the  good  it  may  do 
will  greatly  outweigh  the  prospect  of  an  occasional  assertion  of  an  oxytocic  action. 

10.  Influenza. — Epidemic  influenza  is  responsible  for  many  premature 
births ;  failure  of  such  children  to  survive  should  not  be  attributed  to  congenital 
transmission  when  we  bear  in  mind  the  high  mortality  of  prematurity  in  general. 
In  regard  to  the  possibility  of  actual  transmission  of  the  disease,  Ballantyne 
states  that  he  has  had  several  personal  cases  of  influenza  contracted  in  iitero. 

17 


258  PATHOLOGICAL  PREGNANCY. 

11.  Fetal  Sepsis. — If  the  mother  is  iil  a  state  of  sepsis  from  pneumo- 
cocci,  streptococci,  staphylococci,  or  Bacillus  coli,  and  the  placenta  allows  them 
to  pass  into  the  fetal  circulation,  a  condition  of  intrauterine  sepsis  necessarily 
results,  and  some  of  the  fetal  organs  will  probably  be  attacked.  Pneumococcus 
sepsis,  fetal  pneumonia:  Pregnant  women  with  pneumonia  frequently  abort,  and, 
according  to  Vinay,  60  per  cent,  of  their  infants  born  alive  die  shortly  after 
birth,  presenting  at  autopsy  evidences  of  pulmonary  hepatization.  The  sooner 
delivery  can  occur  after  the  mother  is  attacked,  the  more  likely  are  the  children 
to  survive.  The  claim  that  these  alterations  in  the  lung  are  pneumonic  has  been 
disputed  in  the  belief  that  the  fetus  undergoing  air-hunger  from  the  maternal 
pneumonia  attempts  inspiration  and  aspirates  amniotic  fluid,  as  a  result  of  which 
the  lung  presents  a  characteristic  appearance  at  autopsy.  Admitting  the  proba- 
bility of  this  claim,  it  is  still  certain  that  fetal  pneumonia  may  occur  as  a  feature 
of  pneumococcus  sepsis.  Streptococcus  sepsis:  Streptococcus  pyogenes  has  been 
found  in  the  blood  and  tissues  of  the  fetus  in  connection  with  various  fetal 
diseases  of  the  mother.  Most  recorded  cases  appear  to  be  examples  of  pure 
sepsis  without  lesions.  The  streptococcus  of  erysipelas  appears  to  have  caused 
fetal  endocarditis  and  other  lesions,  and  Moncorvo  thinks  that  congenital  ele- 
phantiasis may  originate  in  this  way.  Staphylococcus  sepsis:  The  staphylococ- 
cus has  been  found  in  fetal  tissues  in  a  case  of  typhoid  fever.  If  acute  articular 
rheumatism,  as  has  been  claimed,  is  due  to  the  staphylococcus,  the  few  recorded 
cases  of  fetal  rheumatism  may  be  cited  in  this  connection.  Bacillus  coli  sepsis: 
Ballantyne  states,  without  references,  that  Bacillus  coli  has  been  found  in  the 
fetus. 

12.  Miscellaneous. — Anthrax  has  been  transmitted  from  the  mother  to 
the  fetus  in  a  few  instances,  the  bacillus  of  the  disease  being  recognized  in 
the  fetal  tissues.  Hydrophobia  is  transmissible  by  animal  experiment,  but 
fetal  hydrophobia  in  mankind  has  never  been  described.  Tetanus:  We  know 
of  no  case  of  association  of  tetanus  in  the  mother  with  trismus  in  the  newly 
born.  Naturally,  in  the  vast  majority  of  recorded  cases  of  the  latter  the  fetus 
was  not  exposed  to  infection  from  the  mother.  Yellow  fever:  Pregnant  women 
with  this  affection  often  abort.  When  they  recover  without  miscarriage,  the  chil- 
dren afterward  born  are  said  to  be  immune  to  the  disease.  This  statement,  made 
upon  the  authority  of  individual  observers,  is  not  generally  credited.  Relapsing 
fever  is  known  to  be  transmissible  to  the  fetus.  According  to  Klein wachter, 
there  is  a  fetal  typhus.  Ballantyne  mentions  a  fetal  varicella.  Kleinwachter 
mentions  fetal  epidemic  parotitis.  Fetal  pertussis  is  mentioned  by  Ballantyne. 
Of  epidemic  cerebrospinal  meningitis  a  single  case  is  on  record  (Ballantyne). 

13.  Tuberculosis. — When  a  consumptive  woman  becomes  pregnant,  she 
tends  to  abort  in  proportion  as  the  disease  is  advanced.  Thus,  it  has  been 
computed  that  about  15  per  cent,  of  abortions  occur  in  the  first,  and  2,2  per 
cent,  in  the  second,  stage  of  phthisis.  When  the  pregnancy  is  not  interrupted, 
the  offspring  of  these  women  are  usually  delicate  and  undersized,  and  after 
developing  the  so-called  strumous  or  tuberculous  diathesis,  they  tend  to  fall  a 
prey  to  the  disease.  Before  the  discovery  of  the  infectious  character  of  tuber- 
culous matter  and  the  specific  germ  of  the  disease,  it  was  generally  beheved  that 
the  phthisical  individual  practically  acquired  the  disease  in  utero.  The  apparent 
relative  immunity  of  the  fetal  and  placental  tissues  toward  direct  implication  in 
the  tuberculous  processes  has,  however,  led  to  the  conviction  that  antenatal 
infection  is  a  mere  curiosity  in  pathology,  and  that  the  mother  transmits  to  her 
fetus  nothing  more  than  a  lack  of  resistance  to  disease.  There  is  a  species  of 
fetal  tuberculosis  that  may  be  of  common  occurrence.     The  toxic  products  of  the 


ANTENATAL  DISEASES  OF   THE  FETUS.  259 

disease,  circulating  in  the  maternal  blood,  should  certainly  be  able  to  enter  the 
fetal  vessels,  and  there  give  rise  to  a  train  of  symptoms  similar  to  those  which 
follow  injections  of  tuberculin  in  large  doses.  It  can  hardly  be  doubted  that 
exposure  to  this  influence  often  causes  fetal  death,  especially  in  the  later  months 
of  pregnancy;  while  those  children  who  do  not  die  in  utero  exhibit  at  birth  the 
delicacy  and  undersize  already  mentioned.  The  fact  that  bacilli  are  seldom 
found  in  the  blood  of  tuberculous  individuals,  and  then,  as  a  rule,  only  in  miliary 
tuberculosis,  furnishes  a  strong  argument  against  the  existence  of  bacillary 
emigration  from  the  mother  to  the  fetus  even  if  the  placenta  were  permeable. 

Actual  Fetal  Tuberculosis. — This  condition  has  been  recognized  a  very  few 
times  only  (between  twenty  and  thirty).  There  are  two  distinct  types:  viz., 
simple  bacillosis  without  lesions,  and  tuberculosis  proper.  In  the  former  the 
fetal  tissues  are  shown  to  contain  bacilli  by  the  microscope,  by  culture,  or 
by  animal  inoculation.  In  the  latter  tubercles  are  recognizable.  Accord- 
ing to  some  authors,  the  lesions  are  almost  necessarily  located  in  the  organs 
first  traversed  by  the  placental  blood,  especially  the  liver  and  spleen.  This 
claim  remains  to  be  proved,  as  a  great  variety  of  organs  may  be  attacked 
by  the  disease.  In  some  of  the  cases  the  placenta  or  endometrium  was  also 
tuberculous,  but  there  is  no  necessary  relationship  in  this  particular. 

The  great  infrequency  of  fetal  tuberculosis  is  to  be  explained  as  follows: 
Cases  are  undoubtedly  overlooked,  and  some  pediatrists — Holt,  for  example — 
are  inclined  to  look  upon  cases  of  tuberculosis  in  extremely  young  children  as  of 
fetal  origin.  But  even  with  this  concession  the  disease  is  notably  rare,  because 
two  conditions  are  doubtless  indispensable  factors  in  its  production:  (i)  The 
mother  must  be  suffering  from  general  miliary  tuberculosis,  otherwise  her  blood 
will  contain  no  bacilli;  and  (2)  the  placenta  must  be  the  seat  of  some  lesion 
whereby  the  bacilli  are  suffered  to  enter  the  fetal  blood. 

The  possibility  that  fetal  tuberculosis  may  be  derived  from  a  tuberculous 
ovum,  or  even  infected  spermatozoa,  has  been  subjected  to  experimental  testing 
in  animals.  Paternal  infection  has  been  deemed  impossible,  but  contamination 
through  the  ovum  is  regarded  as  a  possibility.  Tuberculosis  of  the  ovary  is  now 
known  to  occur  frequently,  and  in  some  cases  the  disease  has  even  appeared  to 
attack  the  Graafian  follicles  by  preference.  As  to  the  fate  of  an  ovum  proceed- 
ing from  such  a  follicle  we  can  only  make  conjectures.  Statistics  appear  to 
show  that  early  abortion  occurs  very  rarely  in  tuberculous  women,  but  these 
figures  are  based  on  pulmonary  tuberculosis  only.  Genital  tuberculosis  is,  of 
course,  a  different  type  of  disease. 

14.  Syphilis. — Fetal  syphilis — i.  e.,  syphilis  which  asserts  itself  during 
the  fetal  period  for  the  first  time — must  be  distinguished  from  syphilis 
which  is  contracted  perhaps  during  fetal  life,  but  on  account  of  the  prolonged 
incubation  period  does  not  assert  itself  until  after  delivery — usually  not  until 
the  second  month  of  extrauterine  life.  We  know  little  of  germinal  and  embry- 
onal syphilis.  Antenatal  syphilis,  then,  is  to-day  synonymous  with  fetal 
syphilis.  The  effects  of  the  syphilitic  poison  or  poisons  upon  the  fetus  are, 
speaking  broadly,  the  same  as  those  seen  in  adult  life:  viz.,  specific  and  non- 
specific, or,  in  other  words,  syphilitic  and  parasyphilitic.  The  latter  changes  in 
the  fetus  are  essentially  dystrophic,  and  comprise  a  long  series  of  modifications 
of  development  in  various  organs  and  tissues.  All  the  structures  which  make 
up  the  ovum  may  be  attacked  by  the  disease — fetus,  liquor  amnii,  membranes, 
cord,  and  placenta.  The  specific  alterations  induced  by  fetal  syphilis  are,  in 
brief,  as  follows:  Liver:  While  this  may  escape  injury,  it  is  very  commonly 
affected,  being  enlarged  and  hardened  and  strewn  with  whitish  dots.     These 


260  PATHOLOGICAL  PREGNANCY. 

changes  are  the  results  of  a  diffuse  interstitial  cirrhosis,  the  white  granules  con- 
sisting of  miliary  gummata.  Larger  gummy  nodules  are  seldom  seen  in  the  fetal 
liver.  Lungs:  These  are  often  the  seat  of  interstitial  pneumonia  and  miliary 
gummata,  the  changes  being  analogous  to  those  found  in  the  liver.  The  so-called 
white  pneumonia  which  is  sometimes  encountered  consists  of  patches  of  air-cells 
filled  with  epitheHal  debris  in  a  state  of  fatty  degeneration.  Heart  and  Vessels: 
The  heart  is  seldom  attacked  beyond  the  deposition  of  a  few  mihary  gummata, 
but  the  vessels  are  usually  the  seat  of  generalized  periarteritis  and  endarteritis 
with  resulting  obstruction  of  the  lumina  of  the  vessels  attacked.  Thymus:  The 
lesions  of  this  organ,  largely  cystic,  do  not  appear  to  be  specific  in  character. 
Kidneys:  These  organs  are  not  usually  implicated  by  the  disease.  Intestines:  Fetal 
peritonitis  is  largely  of  syphilitic  origin.  Osseous  System:  The  diaphyses  and  epi- 
physes of  the  long  bones  are  separated  by  a  peculiar  linear  tract  which  is  of  vary- 
ing breadth,  yellow,  and  irregular  (Wegner's  line).  This  formation  represents 
the  occurrence  of  syphilitic  osteochondritis.  The  peculiar  color  is  due  to  the  fatty 
or  cheesy  metamorphosis  of  the  products  of  inflammation.  Integument:  The 
bullae  of  pemphigus  of  the  newly  born  may  develop  in  utero  as  a  part  of  the  fetal 
evolution  of  the  disease.  This  is  also  true  to  a  limited  extent  of  moist  papules, 
condylomata,  etc.  A  pseudo-ichthyotic  condition  of  the  skin  representing 
extensive  desquamation  is  sometimes  seen.  The  changes  which  occur  in  the 
fetal  appendages  are  described  under  the  disease  of  the  latter. 

Transmission. — There  is  no  necessary  connection  between  the  date  upon 
which  the  germ  first  attacks  the  fetal  tissues  and  the  period  of  an  explosion  of 
symptoms.  The  fetus  may  contract  the  disease,  but  it  may  be  the  newly  bom 
or  older  infant  that  first  exhibits  the  specific  lesions.  Or  the  ovum  may  contract 
the  disease  and  the  fetus  suffer  from  it.  In  describing  fetal  syphilis  we  must 
confine  ourselves  largely  to  the  outbreak  itself.  We  must  also  bear  in  mind  the 
non-specific  lesions  from  which  the  fetus  may  suffer,  (i)  To  take  the  most 
familiar  conditions  conceivable  in  this  connection,  let  us  suppose  that  a  woman 
some  months  pregnant  undergoes  an  explosion  of  secondary  syphilis  of  a  severe 
type.  The  placenta  is  attacked  along  with  most  of  the  other  tissues  of  the  body, 
and  the.  fetus  dies  before  it  has  time  to  share  the  maternal  disease.  This  is 
the  most  common  type  of  the  relations  which  subsist  between  syphilis  and  the 
fetus,  and  corresponds  to  the  great  frequency  of  abortion  and  miscarriage  in 
syphilitic  women.  Children  born  under  these  circumstances  should  have  nothing 
peculiar  in  their  appearance.  (2)  If  the  fetus  is  not  killed  outright,  it  is  almost 
certain  that  the  germs  of  the  disease  will  traverse  the  placenta  and  set  up  some 
of  the  visceral  changes  which  have  already  been  indicated.  Unless  this  infec- 
tion occurs  near  term,  a  fetus  thus  rendered  profoundly  syphilitic  is  very 
likely  to  die  in  utero  from  the  disease  itself;  and  when  expelled,  it  will  present 
a  typical  picture  of  fetal  syphilis,  including  maceration.  If  such  a  child  is  born 
alive  but  hopelessly  diseased,  we  have  the  so-called  syphilis  neonatorum,  which 
should  not  be  confounded  with  infantile  syphilis  proper,  which  represents  the 
outbreak  of  an  infection  received  in  utero.  (3)  If  the  germs  of  the  disease  do 
not  traverse  the  placenta,  at  least  at  the  outset,  the  fetus  is  exposed  to  the  toxic 
principle  of  the  disease  as  it  circulates  through  the  maternal  blood,  and,  even 
aside  from  this,  it  must  perhaps  suffer  to  some  extent  from  the  anemia  and  mal- 
nutrition of  the  mother  which  are  due  to  the  action  of  this  poison.  Directly 
and  indirectly,  then,  the  fetal  development  is  more  or  less  interrupted,  just  as  it 
would  be  in  tuberculosis,  alcoholism,  etc.  The  fetus  may  be  bom  in  this  condi- 
tion alone,  or,  as  is  much  more  likely, — at  least  early  in  the  maternal  disease, — 
some  of  the  maternal  germs  finally  penetrate  the  placenta.     The  fetus  when 


ANTENATAL  DISEASES  OF   THE  FETUS.  261 

born  is  found  to  be  small  and  feeble,  with  certain  evidences  of  prematurity,  not 
yet  syphilitic  perhaps,  but  containing  the  germs  of  the  disease.  After  several 
weeks  of  extrauterine  life  the  -disease  becomes  active,  and  the  usual  pheno- 
mena of  secondary  syphilis -develop.  This  is  the  familiar  type  of  congenital, 
hereditary,  or  infantile  syphilis.  In  some  cases  the  activity  does  not  occur 
until  late  in  childhood  or  even  until  adolescence  (tardy  hereditary  syphilis) ;  such 
individuals  are  peculiarly  afflicted  with  the  evidences  of  dystrophy  of  syphilitic 
origin.  (4)  As  intimated,  it  is  possible  for  a  fetus  to  escape  bacillary  infection 
in  utero,  and  develop  no  syphilitic  lesions  in  after  years,  although  the  child  may 
present  evidences  of  dystrophy.  (5)  Finally,  it  is  possible  for  an  infant  to  escape 
syphilis  in  utero  altogether — not  only  its  specific  but  non-specific  influence.  All 
the  preceding  types  may  occur  in  the  pregnancies  of  one  woman.  It  is  impos- 
sible in  a  work  of  this  sort  to  enter  into  the  discussion  of  such  subjects  as  direct 
paternal  infection,  syphilis  of  the  unimpregnated  ovum,  infection  of  the  mother 
from  the  fetus,  immunity,  Colles's  and  Profeta's  laws,  etc.  Syphilis  contracted 
before  or  near  the  time  of  conception  is  said  to  be  more  generally  fatal  to  the  fetus 
than  when  the  mother  is  infected  some  weeks  or  months  after  impregnation  has 
occurred;  that  is,  the  proportion  of  abortions  and  of  fetal  syphilis  will  be  higher 
in  the  former  case. 

Treatment. — The  mother  of  course  requires  treatment  for  syphilis,  and  there 
is  no  special  indication  for  the  treatment  of  the  fetus.  Mercury  and  potassium 
iodide  should  be  given  as  early  as  possible  and  continued  throughout  pregnancy. 
Very  recently  an  attempt  has  been  made  to  treat  the  fetus  locally  by  the  use  of 
medicated  tampons  introduced  into  the  vaginal  vault.  The  mercury  was  used  in 
the  form  of  ointment,  mixed  with  an  equal  or  a  double  quantity  of  cocoa-butter 
(Riehl).  In  theory  a  special  indication  should  exist  for  the  fetus  when  a  syphilitic 
husband  has  impregnated  his  wife.  In  these  cases  the  fetus  is  supposed  to  infect 
its  mother,  and  proper  local  medication  might  prevent  this  catastrophe  if  it  really 
ever  occurs.  Riehl's  method  would  be  applicable  here,  but  a  more  rational 
treatment  would  be  to  empty  the  uterus  at  once.  In  regard  to  the  routine  prac- 
tice of  abortion  in  syphilis,  the  chance  of  curing  the  fetus  is  so  considerable  that 
it  is  contraindicated  as  a  general  resource  and  is  indicated  only  under  special 
contingencies. 

2.  Acute  Poisoning. — Chloroform:  There  is  no  longer  any  doubt  that  chloro- 
form used  as  an  anesthetic  in  labor  tends  to  cause  fetal  asphyxia.  This  is  demon- 
strated by  the  results  of  Csesarean  section,  and  is,  in  fact,  something  of  a  con- 
traindication to  the  use  of  anesthesia  in  labor.  Chloroform  has  never  been 
recovered  from  the  fetal  blood.  Fehling  believes  that  it  can  determine  the 
presence  of  fetal  icterus  and  albuminuria.  Ether:  What  has  been  said  of  chloro- 
form applies  equally  well  to  ether.  (See  Anesthesia  in  Obstetrics,  Part  X.) 
Coal-gas:  The  pregnant  woman  sometimes  inhales  this  gas  with  or  without 
suicidal  intent.  In  cases  in  which  the  mothers  escaped  death  they  sooner  or 
later  were  delivered  of  dead  or  macerated  children.  This  gas  is  extremely  poi- 
sonous to  the  fetus.  Nevertheless  there  is  no  evidence  that  the  gas  enters  the 
fetal  circulation  to  any  extent.  Alcohol:  Cases  are  upon  record  in  which  the 
ingestion  by  pregnant  women  of  an  inordinate  amount  of  alcohol  has  apparently 
caused  fetal  death.  Mineral  Asids:  In  cases  of  acute  poisoning  with  sul- 
phuric acid  the  fetus  appears  to  have  shown  some  of  the  dehydrating  action  of 
this  substance,  but  only  in  its  skin,  which  is  hard  and  brown.  Metalloids: 
In  phosphorus-poisoning  the  fetus  shows  very  much  the  same  lesions  as  the 
mother,  it  being  certain  that  this  substance  passes  through  the  placenta.     In 


262  PATHOLOGICAL  PREGNANCY. 

acute  arsenical  poisoning,  bowever,  the  ovum  gives  no  evidence  that  this  drug 
reaches  the  fetal  tissues. 

3.  Chronic  Poisoning. — Plumbism:  In  pregnant  women  suffering  from 
chronic  lead-poisoning  abortion  occurs  in  no  less  than  60  per  cent,  of  cases,  and 
children  born  alive  have  a  high  secondary  mortality  and  exhibit  a  marked  ten- 
dency to  convulsions  and  hydrocephaloid  or  rachitiform  malformations  of  the 
head.  The  latter  inheritance  may  even  proceed  from  the  father  alone.  When 
both  parents  are  affected,  the  child  morbidity  is  increased.  It  is  not  known  to 
a  certainty  whether  the  lead  kills  the  fetus  outright  or  simply  excites  labor.  The 
metal  has  been  found  in  the  fetal  viscera,  where  it  has  apparently  set  up  inflam- 
matory disturbances.  On  the  other  hand,  preparations  of  lead  have  a  notorious 
tendency  to  produce  abortion,  and  are  much  used  with  this  criminal  intent. 
Mercurialism:  In  pregnant  women  who  are  subject  to  chronic  mercurialism  the 
tendency  to  abortion  and  premature  delivery  is  high,  although  the  exact  ratio 
is  unknown.  When  syphilis  is  present,  large  medicinal  doses  of  mercury  are 
known  to  prevent  abortion.  The  metal  has  been  found  in  the  fetal  tissues.  A 
curious  fact  repeatedly  noted  is  the  improvement  in  health  which  follows  preg- 
nancy in  these  cases.  Thus,  a  worker  in  a  mirror  or  barometer  factory  may  have 
her  salivation,  tremor,  etc.,  disappear  after  conception,  to  return  when  abor- 
tion has  occurred.  This  apparent  protecting  action  of  the  embryo  suggests 
Colles's  law  of  maternal  immunity  in  syphilis.  The  action  of  mercury  upon 
pregnancy  seems  to  be  less  severe  than  that  of  lead.  Phosphorism:  De  Caulbry, 
Borri,  and  others  state  that  pregnant  workers  in  match  factories  undergo  abor- 
tion very  frequently.  But  few  data  are  available  regarding  chronic  phosphorus- 
poisoning.  Arsenicism:  We  know  even  less  of  arsenic  than  of  phosphorus  in 
regard  to  the  effects  of  chronic  maternal  poisoning  upon  the  fetus.  Alcoholism: 
It  was  not  until  1900  that  Nicloux*  was  able  to  demonstrate  that  the  drug  in 
question  enters  the  fetal  circulation.  He  gave  a  woman  milk-punches  after  she 
was  well  along  toward  delivery,  and  was  able  to  distil  some  of  the  alcohol  from 
the  blood  of  the  umbilical  vein.  In  regard  to  the  effects  of  alcoholism  on  preg- 
nancy, as  studied  in  a  series  of  chronic  drunkards,!  there  is  no  evidence  of  any 
strong  tendency  to  abortion.  Still-birth  is  quite  common,  but  the  principal 
effect  of  alcohol  upon  the  fetus  is  shown  in  the  extraordinary  tendency  to  ner- 
vous and  cerebral  disease,  malformation,  and  degeneracy  exhibited  by  these 
children  as  they  grow  up.  Alcohol  in  the  fetal  circulation  tends  to  arrest  the 
highest  development.  Morphinism:  In  pregnant  morphinomaniacs  no  especial 
tendency  to  abortion  or  premature  delivery  has  been  noted.  The  children  born 
to  such  women  often  appear  healthy  in  every  respect.  Morphin,  however, 
has  been  recovered  from  the  fetal  tissues.  There  is  considerable  evidence 
that  such  fetuses  are  more  likely  than  others  to  require  resuscitation  at  birth. 
I  have  observed  that  attempts  at  withdrawal  of  the  morphin  during  gestation 
have  been  followed  by  excessive  fetal  movements,  which  subsided  when  the  use 
of  the  drug  was  renewed.  This  phenomenon  suggests  that  the  fetus  has  acquired 
a  tolerance  to  the  narcotic.  Nicotinism:  The  pregnancies  in  many  tobacco  fac- 
tories, etc.,  are  not  interrupted,  although  there  is  a  very  high  mortality  among 
the  children  of  these  women. 

4.  Dyscrasic  Conditions. — Diabetes:  Fetal  diabetes  is  not  actually  known  to 
exist,  but  the  sugar  in  the  maternal  blood  may  be  able  to  pass  into  the  circula- 
tion of  the  fetus  and  give  rise  to  various  disturbances.  Sugar  has  been  found 
in  the  amniotic  fluid  in  cases  of  diabetes,  and  also  in  the  urine  of  the  new-born. 
Artificial  (phloridzin)  glycosuria  in  the  mother  causes  sugar  to  appear  in  the 

*"  L'0bst6trique,"  1900,  t.  v.  t  Sullivan  :  "Jour.  Mental  Science,"  1899 


ANTENATAL   DISEASES   OF   THE   FETUS.  263 

fetal  urine.  According  to  Vinay,  pregnancy  in  diabetic  women  is  interrupted 
in  over  a  third  of  the  cases,  while  about  one-half  of  the  children  born  alive  do  not 
survive;  but  this  need  not  be  .due  to  the  sugar  directly,  because  diabetes  often 
leads  to  disease  of  the  endometrium.  A  Ihuminuria,  Renal  Disease,  Toxemia  of 
Pregnancy,  Eclampsia  of  the  Mother:  The  children  are  often  still-born  or  die 
soon  after  birth.  All  in  all,  the  chance  of  survival  of  these  children  is  very 
small.  They  are  undersized  and  below  weight,  even  when  fully  matured. 
They  are  very  prone  to  be  seized  with  convulsions  after  birth,  and,'  according 
to  some,  even  in  utero.  Autopsies  upon  many  of  these  fetuses  have  revealed  no 
constant  pathological  changes.  In  fact,  the  obscurity  which  attaches  to  the 
entire  problem  of  eclampsia,  etc.,  in  the  mother,  extends  to  the  fetus.  (Compare 
Section  X,  Part  III.)  Leukemia:  Women  with  this  affection  seldom  become 
pregnant.  In  the  few  recorded  cases  the  infant  was  sound.  Cancerous  Ca- 
chexia: Still-births  are  very  common,  while  children  born  alive  are  very  weakly 
and  in  many  cases  succumb  soon  after  birth.  The  toxins  which  must  be  present 
in  the  maternal  blood  appear  to  exert  an  influence  on  the  fetus  which  is  similar 
to  that  observed  in  tuberculosis. 

5.  Cardiac  Diseases. — Endocarditis :  Its  presence  is  revealed  by  changes  anal- 
ogous to  those  of  the  same  disease  in  extrauterine  life:  viz.,  thickening  of  the 
endocardium,  contraction  of  the  orifices,  and  valvular  lesions.  The  causes  are 
very  obscure.  The  clinical  features  of  this  affection  are  as  interesting  as  its 
pathogeny  is  obscure.  It  has  been  diagnosticated  a  number  of  times  during 
intrauterine  life  through  auscultation  of  the  fetal  heart,  systolic  murmurs  having 
been  readily  apparent.  Auscultation  after  delivery  gave  the  same  sounds  in 
living  children,  while  autopsy  confirmed  the  diagnosis  in  the  case  of  non-survival. 
The  presence  of  a  uterine  souffle  under  these  circumstances  might  readily  pro- 
duce an  illusion.  As  with  so  many  other  presumably  fetal  diseases,  it  appears 
quite  probable  that  what  is  called  fetal  endocarditis  represents  an  embryonal 
anomaly.  Fetuses  with  this  affection  are  very  prone  to  exhibit  one  or  more 
malformations  of  other  tissues  (hare-lip,  cleft  palate,  imperforate  anus,  horseshoe 
kidney.  Mongoloid  idiocy,  etc.).  Atheroma:  At  least  one  case  of  atheroma  of 
the  aorta  and  pulmonary  artery  is  known.  The  fetus  was  premature  and  sur- 
vived about  two  weeks.  It  is  hardly  possible  for  such  a  condition  to  develop 
in  so  short  a  time  after  birth. 

6.  Diseases  of  the  Alimentary  Tract. — Ascites:  As  a  rule,  this  condition  is  due 
to  fetal  peritonitis,  and  is  thus  a  result  of  disease.  It  is  considered  to  some 
extent  under  "  Dystocia  of  Fetal  Origin."  Peritonitis:  This  disease  is  usually, 
but  not  necessarily,  accompanied  by  effusion  (see  Ascites).  The  adhesions  which 
form  may  cause  various  late  malformations  in  the  abdominal  cavity.  Fetal 
peritonitis  may  be  due  to  hydramnios  or  syphilis,  but  in  very  many  cases  appears 
to  have  arisen  idiopathically  or  from  unknown  maternal  causes.  Congenital 
Obliteration  of  the  Bile-ducts:  This  interesting  affection  is  one  of  the  best  exam- 
ples of  the  diseases  of  the  fetal  period.  It  appears  to  be  analogous  to  biliary 
cirrhosis  of  the  liver  in  adult  life.  The  initial  process,  the  nature  of  which  is 
unknown,  leads  to  obstruction  of  the  biliary  passages,- which  is  accompanied  or 
followed  by  cirrhosis  of  the  liver  and  jaundice.  The  fetus  is  born  with  icterus, 
and  the  condition  is  thus  one  of  icterus  neonatorum,  under  which  name  it  is  fully 
described  (Part  IX).  Congenital  Hypertrophic  Stenosis  of  the  Pylorus:  This 
belongs  clinically  under  the  diseases  of  the  newly  born,  but  undoubtedly  develops 
in  utero.  It  possesses  a  nervous  or  spasmodic  element  which  precedes  or  is  asso- 
ciated with  hypertrophy  of  the  pylorus  and  the  wall  of  the  stomach.  Something 
analogous  to  this  union  of  nervous  spasm  and  hypertrophy  is  seen  in  the  urethra 


264  PATHOLOGICAL  PREGNANCY. 

and  bladder,  also  the  colon.     Adiscellaneous:  Ballantyne,  in  addition  to  the  con- 
genital hypertrophy  of  the  colon,  speaks  of  a  "  congenital  volvulus." 

7.  Diseases  of  the  Nervous  System. — Congenital  Hydrocephalus  (Figs.  435  and 
436). — Definition:  An  excessive  accumulation  of  cerebrospinal  fluid  within  the 
brain  or  its  membranes,  causing  enlargement  of  the  skull.  The  serous  effusion  is 
generally  confined  to  the  ventricles,  although  it  may  be  found  in  the  interstices 
of  the  pia  mater,  in  the  parenchyma  of  the  cerebrum,  or  between  the  arachnoid 
and  the  dura  mater.  (See  also  "  Dystocia  of  Fetal  Origin,"  Part  V.)  Frequency: 
This  affection  is  rare,  occurring  once  in  about  3000  deliveries.  Pathology:  The 
skull  becomes  enlarged,  sometimes  enormously  so,  by  the  pressure  of  the  in- 
creasing quantity  of  the  fluid,  and  the  edges  of  the  sutures  are  separated 
more  or  less  widely;  the  bones  become  very  thin,  sometimes  like  parchment; 
the  skull  is  much  larger  proportionately  than  the  face,  the  forehead  being 
especially  prominent.  The  head  may  even  reach  the  size  of  that  of  an  adult; 
the  body,  as  a  rule,  is  normally  developed,  and  is  of  the  size  which  corresponds 
to  the  period  of  pregnancy,  but  is  often  wrinkled  and  emaciated.  Other  mal- 
formations, as  meningocele,  frequently  coexist,  and  hydramnios  is  a  common 


Figs.  435  and  436. — Hydrocephalus.     Two  Views  of  the  Same  Skull.    (J  natural  size.) 

— {Author's  collection.) 

accompaniment.  The  quantity  of  liquid  in  the  ventricles  may  reach  several 
pints.  The  head  is  shaped  like  a  wedge,  with  the  base  upward;  the  charac- 
teristic deformity  produced  by  the  normal  size  of  the  face  and  lower  part  of 
the  skull,  surmounted  by  the  enormously  distended  upper  part,  is  very 
striking.  The  eyes  are  very  deeply  set,  and  their  axes  point  obliquely  inward, 
so  that  they  look  crossed,  and  the  deformity  is  often  hideous,  from  the  promi- 
nence of  the  eyes  and  the  overhanging  forehead  (Fig.  435).  With  this  affection 
polyhydramnios  is  commonly  present,  but  rarely  will  hydrorrhachis  be  found. 
There  is  a  decided  tendency,  on  the  part  of  the  mother,  to  rupture  of  the 
uterus.  Etiology:  This  is  not  positively  settled.  It  has  been  observed  to  occur 
several  times  in  children  of  the  same  mother:  in  one  case  six  (Gohlis) ;  in  another 
seven  (Peter  Frank).  Very  rarely  have  abnormal  conditions  been  found  in  the 
mother.  Frequent  anomalies  are  present  in  the  fetus  itself  and  its  surrounding 
parts;  namely,  spina  bifida,  club-foot,  large  quantities  of  liquor  amnii,  anasarca 
and  ascites,  and  congenital  rickets.  Most  of  these  defects  are  due  to  the  same 
cause  as  the  hydrocephalus.  Then,  too,  may  occur  diaphragmatic  hernia,  absence 
of  one  kidney,  etc.  (Winckel).  Diagnosis:  The  condition  is  seldom  recognized 
during  pregnancy.     In  a  small  proportion  of  cases  hydramnios  coexists.     Vicious 


ANTENATAL  DISEASES  OF  THE  FETUS.  265 

presentations  are  often  present.  Exceptionally  certain  phenomena  have  led  to 
the  making  of  a  diagnosis,  such  as  the  absence  of  ballottement  and  parchment- 
like crepitation  and  fluctuation. in  the  fetal  head.     (See  Fetal  Dystocia,  Part  V.) 

Meningocele;  Encephalocele;  Hydrencephalocele. — Meningocele  (Fig.  328)  con- 
sists in  hernia  or  tumor  in  which  there  is  a  protrusion  of  the  cerebral  mem- 
branes through  an  opening  in  the  skull.  These  form  a  sac,  which  may  or 
may  not  contain  cerebrospinal  fluid.  In  encephalocele  (Fig.  330)  there  is  a  pro- 
trusion of  the  brain  substance  which  is  connected  with  the  bulk  of  the  brain 
by  a  constricted  neck  or  pedicle.  In  this  tumor  there  may  or  may  not  be 
fluid.  In  hydrencephalocele  (Fig.  329)  there  is  a  protrusion  of  a  portion  of  the 
brain  substance,  as  in  encephalocele,  but  this  contains  within  its  center  a  cavity 
filled  with  cerebrospinal  fluid  and  communicating  with  the  distended  lateral 
ventricles  of  the  brain. 

Meningocele  is  rarer  than  meningo-encephalocele.  The  occipital  and  fronto- 
nasal regions  form  the  most  frequent  seat  of  these  tumors.  The  size  varies 
from  that  of  an  olive  to  an  egg-plant.  The  tumor  is  always  congenital; 
generally  it  is  round  and  elastic,  soft  and  fluctuating.  Its  reducibility  varies. 
It  is  always  in  or  near  the  median  line.  There  is  pulsation  synchronous  with 
that  of  the  heart.  Convulsions  or  even  coma  may  be  caused  by  compression. 
These  deformities  probably  result  from  an  arrest  of  development  of  the  cranial 
bones.  They  may  be  due  to  arrested  or  defective  development,  or  they  may 
result  from  an  intracranial  inflammation,  terminating  in  bands  of  adhe- 
sion, or  to  a  thinning  of  the  bones  of  the  skull  from  internal  hydrocephalus. 
The  head  itself  may  be  normal  or  hydrocephalic.  Coincident  with  these  tumors 
is  a  softening  of  the  cranial  bones,  which  renders  expression  of  the  head  easier 
in  labor.  They  do  not  often  offer  an  obstruction  to  delivery,  for,  on  account 
of  their  position,  they  are  expelled  either  before  or  after  the  head  itself.  The 
maximum  degree  of  obstruction  will  obtain  when  the  tumor  is  of  large 
size,  with  short  pedicle  and  a  lateral  position.  Prognosis  for  both  mother 
and  child  is  much  better  than  in  cases  of  congenital  hydrocephalus.  All  diffi- 
culty in  the  expulsion  of  the  fetus  is,  as  a  rule,  obviated  by  puncture  of  the  sac. 
After  birth  the  tumor  should  be  carefully  guarded  from  any  friction  or  injury. 
(See  Fetal  Dystocia,  Part  V.) 

Spina  Bifida  (Figs.  335,  336,  337). — This  is  a  defect  in  the  vertebral  canal, 
which  consists  of  a  fluid  tumor  formed  by  the  protrusion  of  some  part  of  the 
contents  of  the  canal.  It  is  found  at  any  point  of  the  spinal  column,  but  most 
frequently  at  the  cervical  or  near  the  end  of  the  dorsal  region.  Among  the  con- 
genital deformities  it  is  one  of  the  most  frequent.  Spina  bifida  is  thought  to  be 
due  to  early  arrested  development,  taking  place  generally  before  the  segmentation 
of  the  cord.  Since  the  dorsal  vertebral  arches  fuse  more  rapidly  than  the 
cervical  or  lumbar,  there  is  more  opportunity  for  the  defect  to  occur  in  the 
two  latter  regions.  There  are  two  degrees  of  this  malformation:  («)  Hydror- 
rhachis  externa — in  which  the  liquid  is  between  the  cord  and  its  envelopes  or 
in  the  midst  of  the  cord  in  the  ependymal  cavity;  (/J)  Hydrorrhachis  interna 
constitutes  a  meningocele.  In  hydrorrhachis  interna  the  tumor  contains  not  only 
the  cord  but  also  the  spinal  nerves  arising  from  it.  The  tumor  is,  as  a  rule, 
associated  with  spina  bifida,  though  this  is  not  always  the  case.  It  ma}^  be  sessile 
or  pedunculated,  depending  upon  the  extent  of  the  fissure.  The  latter  may 
be  in  the  vertebral  bodies  or  the  tumor  may  protrude  through  the  intervertebral 
notch  or  foramen,  and  point  anteriorly — spina  bifida  occtilta.  Although  the 
tumor  is  most  often  single,  it  may  be  multiple  or  it  may  exist  in  two 
regions  of  the  canal  at  the  same  time.     It  may  be  formed  before  the  closure 


266  PATHOLOGICAL  PREGNANCY. 

of  the  central  canal,  or  even  later,  the  accumulated  fluid  causing  it  to  open 
again.  Its  size  varies  considerably,  though  it  is  often  about  the  size  of  a  nut. 
Any  effort  at  crying  or  standing  distends  the  tumor.  Prognosis:  Early  death  is 
frequent,  although  the  victims  of  this  infirmity  have  been  known  to  reach 
fifty  years  of  age.  The  prognosis  is  greatly  influenced  by  the  anatomical 
variety  and  by  the  complications.  The  simple  meningocele  when  covered  by 
skin  is  the  most  favorable  form.  Indeed,  complete  recovery  may  be  hoped 
for.  In  some  cases  hydrocephalus  has  been  known  to  develop  after  cure  of 
the  original  deformity  has  been  obtained  by  operation.  The  diagnosis  is 
not  difficult  as  to  recognition  of  the  general  condition.  It  is  not  so  easy  to 
distinguish  the  different  varieties.  Treatment:  If  the  malformation  is  not 
extreme,  the  treatment  should  be  expectant.  Inflammation  often  follows 
injections  into  the  sac  or  excision  of  the  sac.  The  tumor  should  always  be 
protected  from  pressure,  and  if  it  is  not  covered  by  integument  the  surface 
must  be  kept  aseptic.  For  details  of  the  operation  a  work  on  operative  surgery 
should  be  consulted. 

Cerebral  Diplegia:  While  congenital  spastic  rigidity,  or  Little's  disease,  is 
usually  held  to  have  an  intra-partum  origin,  it  is  by  no  means  certain  that  there 
is  not  in  some  cases  an  antenatal  element.  Chorea:  This  affection  can  some- 
times be  diagnosticated  ante  partum  through  the  choreic  movements  of  the 
fetus.  In  such  cases  we  often  find  a  history  which  might  in  part  account  for 
the  affection,  such  as  history  of  maternal  fright  or  fall,  alcoholic  or  epileptic 
inheritance.  But  chorea  is  sometimes  hereditary,  and  even  a  distinctly  family 
malady,  which  peculiarity  has  been  remarked  in  some  of  these  intrauterine 
cases.  A  distinctly  hereditar}^  affection  has  nothing  to  do  with  the  fetal  stage 
of  intrauterine  life,  hence  chorea  from  this  standpoint  could  not  be  placed 
among  fetal  diseases.  The  same  is  true  of  such  affections  as  Friedreich's 
ataxia,  Thomsen's  disease,  etc.  Maternal  Impressions:  The  nervous  system  of 
the  mother  is  easily  excited,  a  very  slight  irritation  being  capable  of  arousing 
contractions  of  the  uterus.  The  effects  on  the  fetus  of  disturbances  of  the 
maternal  nervous  system  are  probably  most  common  in  the  case  of  women 
with  highly  developed  nervous  organizations.  The  modus  operandi  of  these 
phenomena  is  not  yet  clearly  understood.  Although  there  is  no  apparent 
nervous  connection  between  mother  and  child,  there  may  be  an  alteration  in  the 
blood  caused  by  profound  nervous  disturbance  analogous  to  the  decomposing 
effect  of  an  electrical  current  on  a  chemical  solution.  This  view  would  be  some- 
what supported  by  the  well-known  fact  sometimes  observed  in  women  whose  milk, 
as  a  result  of  strong  emotion,  becomes  a  rank  poison  to  the  child.  Maternal  impres- 
sion is  as  yet  a  mooted  question,  and  reliable  literature  on  it  is  deplorably  defi- 
cient. However,  much  has  been  written  on  both  sides,  and  arguments  and  exam- 
ples have  been  brought  forward  which,  in  their  turn,  would  seem  to  almost  prove 
the  opposed  views.  The  affirmative  side  of  the  subject  has  been  espoused  from  the 
earliest  historical  period.  Instances  pointing  to  the  connection  between  or  the 
dependence  of  congenital  deformities,  both  physical  and  mental,  upon  maternal 
impressions  are  too  numerous  to  be  completely  dismissed  as  coincidences.  On 
the  other  hand,  two  of  the  strongest  arguments  opposing  this  view  have  been 
advanced  as :  ( i )  the  lack  of  nervous  connection  between  mother  and  fetus  and 
(2)  the  alleged  cause  of  the  anomaly  generally  takes  place  at  a  period  not  coinci- 
dent with  that  of  the  embryonic  evolution  of  the  part  affected.  The  whole 
subject  is  at  present  in  an  uncertain  state.  Hereditary  Predispositions  of  the 
Fetus:  Syphilis  with  its  effects  on  the  fetus  has  already  been  noticed.  There 
are  certain  deformities  which  belong  to  certain  families  as  an  inheritance  ("recur- 


ANTENATAL  DISEASES  OF  THE  FETUS.  267 

rent  deformities").  These  may  be  serious  enough  to  cause  death.  One  strange 
affection  that  has  been  noted  is  the  thickening  of  the  fibrous  and  muscular  tissue 
of  the  umbiHcal  vein,  which  diminishes  the  cahbre  to  such  an  extent  that  several 
fetuses  affected  in  this  way  were  born  dead.  They  belonged  to  the  same  mother 
(Leopold). 

8.  Diseases  of  the  Urogenital  Apparatus. — Nephritis:  In  dropsy,  anuria,  etc., 
of  the  newly  born  the  question  of  the  existence  of  intrauterine  nephritis  naturally 
arises.  Cases  in  which  the  children  thus  affected  are  born  alive  have  thus  far 
been  inadequate  for  the  solution  of  the  problem.  Thus,  in  an  observation  cited 
by  Ballantyne  the  child  did  not  become  dropsical  until  the  second  day  after 
birth.  It  survived  three  weeks.  The  existence  of  fetal  nephritis  must  be 
determined  largely  from  a  study  of  unborn  or  still-born  children.  Vesical  Dis- 
tention: This  is  also  considered  among  the  causes  of  dystocia  of  fetal  origin 
(Part  V).  In  any  case  it  is  hardly  a  fetal  disease  nor  due  to  a  disease,  but 
rather  a  condition  associated  with  various  malformations,  some  of  which  are 
responsible  for  its  existence.  Ballantyne  makes  a  special  variety  of  the  type 
which  is  due  to  obstruction  within  the  urethra  and  which  causes  extreme  thick- 
ening of  the  bladder  walls  and  the  ureters.     In  some 

of  these  hypertrophic  cases,  however,  no  obstruction 
can  be  found,  so  that  the  existence  of  a  spasmodic 
stenosis  must  be  assumed,  and  it  is  this  factor  which 
permits  us  to  place  the  affection  among  true  diseases. 
Hydronephrosis :  This  condition,  the  result  of  em- 
bryonal malformations,  is  considered  under  "  Dys- 
tocia of  Fetal  Origin  "  (Part  IX).  Cystic  Degener- 
ation of  the  Kidneys:  The  nature  of  this  condition  is 
obscure.  If  due  to  a  sclerogenous  inflammation  of 
the  urinary  tubules,  it  would  be  a  disease,  otherwise 
it  would  have  to  be  placed  with  fetal  neoplasms  of 
embryonal  origin.  It  is  considered  under  "  Dystocia 
of  Fetal  Origin."  Diseases  of  the  Genitals:  These 
organs,  representing  a  persistence  of  embryonal  struc- 
ture during  the  fetal  period,  are  subject  to  malforma- 
tions rather  than  diseases.  A  congenital  prolapse  of  Fig.  437. — Fetal  Ichthyo- 
the  uterus  is  known  to  occur,  almost  always  in  asso-  ^^^-     (Kyoer  s  case.) 

ciation  with  spina  bifida,  and  is  described  in  great 
detail  by  Ballantyne.     A  red  mass  is  seen  to  project  from  the  vulva  at  birth. 

9.  Antenatal  Cutaneous  Diseases. — There  may  be  a  failure  of  development 
in  any  one  or  all  of  the  specialized  structures  of  the  skin,  evident  at  birth,  as 
happens  in  the  case  of  other  organs.  When  the  lack  is  total  {e.  g.,  atrichia),  it 
is  apt  to  be  accompanied  by  other  deformities.  More  or  less  localized  aberrant 
growth  is  shown  in  the  formation  of  naevi  of  various  sorts — vascular,  pilary,  pig- 
mented, papillomatous,  verrucous.  Aside  from  these  tumors,  the  commonest 
misdirection  of  the  great  embryonic  cellular  activity  is  in  an  increase  of  the 
surface  layers  of  the  epidermis,  the  stratum  corneum  particularly,  which  is  called 
ichthyosis.  There  are  two  varieties,  one  which  is  congenital  and  one  which 
develops  after  a  few  years  have  passed. 

(i)  Ichthyosis  Congenita  (Hyperkeratosis  C  on  genitalis ,  Harlequin  Fetus, 
Universal  Congenital  Keratoma)  (Fig.  437). — The  children  are  usually  premature 
and  immature.  They  rarely  survive  more  than  a  few  da^^s,  but  Sherwell  has 
seen  one  child  live  as  long  as  five  months.  The  skin  is  covered  with  polygonal 
homy  plates,  one-sixteenth  of  an  inch  or  less  in  thickness,  closely  adherent  and 


268 


PATHOLOGICAL  PREGNANCY. 


separated  from  each  other  by  deep  furrows,  which  in  the  neighborhood  of  the 
orifices  may  extend  into  the  cutis  and  consequently  bleed.  Prognosis,  of  course, 
is  unfavorable. 

(2)  Keratolysis  Exfoliativa  is  a  congenital  affection  described  by 
Sangster.  In  it  a  condition  obtains  in  which  the  loosened  horny  stratum 
comes  away  in  large  thin  flakes,  and  leaves  a  reddened  prickle-cell  layer, 
indicating  a  lack  of  the  normal  adhesive  quality  between  the  epidermic 
cells.  The  affection  is  excessively  rare,  and  is  not  very  remotely  related  to 
ichthyosis,  at  least  so  far  as  the  histology  goes. 

(3)  General  Cystic  Elephantiasis. — This  affection  is  thought  to  possess 
a  close  relationship  with  general  fetal  dropsy,  although  it  may  also  be  allied 

to    localized   forms    of    elephantiasis 
(Fig.  438). 

10.    Fetal    Bone    Diseases. — The 
skeleton  diseases  of  the  fetus  repre- 
sent   but    a   single   basic    condition: 
viz.,  irregular  or  imperfect  ossification 
(Fig.   43q).     In  virtue    of   the  great 
mass  of  names  which  have  accumu- 
lated in  the  literature  of  this  condi- 
tion, Ballantyne  proposes  to  abolish 
them  all  and  describe  a  single  affec- 
tion   which    occurs    in    four    types. 
Thus,  Type  A   consists  essentially  of 
a  softening  of  the  bones,  betrayed  by 
the  presence  of  craniotabes  and  curva- 
ture of  the  long  bones.     Type  A  re- 
sembles    extrauterine    rickets    more 
than    any   other    fetal   bone   disease. 
Type  B  exhibits  a  great  fragility  of 
osseous   tissue,   as  well  as  curvature 
and   shortening   of    the   long   bones. 
The  latter  fracture  from  simple  ma- 
nipulations.    While  these  two  types 
have  more  or  less  resemblance.  Type 
C  is  radically  different,  being  charac- 
terized by  extreme  overgrowth  of  the 
epiphyses    of   the    long    bones.     The 
diaphyses     appear      correspondingly 
short.     This   hyperplasia  of  the  car- 
tilaginous epiphyses  of  fetal  hfe  must  be  related  in  some  manner  to  the  enlarge- 
ment of  these  portions  of  the  skeleton  in  extrauterine  rickets.     This  type  of  fetal 
bone  diseases  has  been  known  as  chondrodystrophia  foetalis.     Type  D  is  in  some 
respects  the  converse  of  the  preceding,  and  is  usually  known  as  achondroplasia. 
It  is  seated  chiefly  in  the  limbs  and  trunk,  the  head  being  approximately  normal. 
The  disorder  is  essentially  defective  endochondral  ossification.     The  diaphyses 
of  the  long  bones  are  reduced  in  length  from  a  half  to  a  third,  the  epiphyses  being 
normal.     This  is  the  most  striking  feature  of  the  disease.     The  individual  has 
very  short  limbs,  the  brevity  of  the  lower  extremities  conferring  upon  him  a 
dwarfish  stature.     The  achondroplasic  dwarf  differs  from  the  phocomelus  monster 
largely  because  in  the  latter  the  affection  dates   from  the  embryonal   period, 
while  in  the  former  it  develops  in  the  course  of  fetal  life. 


Fig.  438. — General  Cystic  Elephantiasis. 
—  (Ballantyne.) 


ANTENATAL   DISEASES   OF   THE   FETUS. 


269 


II.  Fetal  Traumatisms. — Injuries  occurring  during  fetal  life  must  be  dis- 
tinguished from  traumatisms  of  intra-partum  origin,  on  the  one  hand,  and  certain 
accidents  which  probably  date' from  the  embryonal  period,  on  the  other.  This 
is  by  no  means  a  simple  matter.  Fetal  traumatisms  may  be  divided  into  wounds 
of  soft  parts,  fractures,  dislocations,  and  amputations. 

Wounds. — Scars  and  circular  defects  of  the  skin  have  been  found  at  times. 
When  the  former  occur  over  what  appear  to  be  badly  united  fractures  of  the 
long  bones,  it  is  possible  that  the  osseous  injury  was  complicated  at  the  time  by 
a  cutaneous  wound.     The  circular  defects  which  are  usually  encountered  on  the 


Fig.  439. — Four  Skulls  showing  Lack  of  Development  of  the  Parietal  Bones  ("  False 

FONTANELLES")    AND   CONGENITAL    FiSSURES   OF   THE    PaRIETAL   AND   OCCIPITAL    BoNES 

("False  Sutures"). — (Author's  collection.) 


scalp  are  due,  it  is  thought,  to  the  tearing  away  by  amniotic  adhesions  of  portions 
of  the  integument  (see  Congenital  Defects  of  the  Skin,  Section  VI). 

Fractures. — Clinically  we  understand  by  this  condition  various  malforma- 
tions which  indicate  more  or  less  imperfect  bony  union  of  a  past  fracture.  Thus, 
observers  have  noted  imitations  of  all  the  terminations  of  fractures  in  extra- 
uterine life,  such  as  nodular  swellings  from  excess  of  callus,  angular  union,  false 
joint,  etc.  In  some  cases  scars  of  the  soft  parts  over  the  fractures  appeared  to 
indicate  that  the  latter  had  been  complicated  by  a  cutaneous  wound.  As  to 
causes  of  fetal  bone  fractures,  it  is  difficult  to  conceive  of  their  occurrence  save 
in  brittle  bones  (see  Fetal  Bone  Diseases,  page  268).  We  know  that  fractures 
occur  intra  partum  under  these  circumstances  (see  Fetal  Birth  Traumatisms, 
Part  IX).     It  is  generally  admitted  that  these  results  of  fetal  injuries  are  very 


270  PATHOLOGICAL  PREGNANCY. 

commonly  associated  with  true  malformations,  in  which  case  they  must  be  re- 
garded as  received  during  the  embryonal  period.  When  it  seems  clear  that  the 
injury  occurred  during  advanced  fetal  life,  we  must  explain  it  by  a  peculiar 
combination  of  causes,  such  as  brittleness  of  bone,  scanty  amniotic  fluid,  and 
excessively  strong  fetal  movements  or  external  violence. 

Dislocations. — What  has  been  said  of  the  nature  of  fetal  fractures  will  hold 
good  for  dislocations.  Thus,  if  recent,  they  suggest  an  intra-partum  origin.  If 
evidently  due,  as  in  some  congenital  dislocations  of  the  hip,  to  defective  develop- 
ment of  structures  forming  the  joint,  the  possibility  of  a  teratological  origin  must 
be  borne  in  mind.  This  conception  of  dislocations  leaves  little  to  be  said  of  their 
occurrence  during  fetal  life  proper.  The  joint  most  frequently  involved  is  the 
hip,  while  the  shoulder  is  sometimes  affected.  These  affections  are  probably 
considered  to  best  advantage  under  the  head  of  birth  traumatisms.     (Part  IX.) 

Amputations. — In  the  condition  known  as  spontaneous  intrauterine  or  con- 
genital amputation  the  defect  must  be  of  a  character  to  show  that  a  limb  once 
existed,  or,  in  other  words,  an  amputation  stump  must  be  present.  The  ampu- 
tated limb,  more  or  less  macerated,  etc.,  may  be  found  in  the  amniotic  fluid  and 
be  expelled  with  the  fetus.  The  amputation  may  afifect  any  portion  of  the  ex- 
tremities, from  a  single  finger  to  an  entire  limb.  The  occasional  presence  of  what 
appear  to  be  rudimentary  digits  upon  the  end  of  the  stump  serves  to  throw  added 
doubt  upon  the  actual  nature  of  these  amputations.  Until  recently  these  injuries 
were  thought  to  be  due  to  constriction  by  amniotic  bands,  this  explanation  being 
found  in  most  text-books  on  obstetrics.  Dermatologists  sought  to  do  away  with 
a  traumatic  element,  and  regard  the  amputation  as  having  been  caused  by  a  sort 
of  sclerodermatous  constriction  of  the  skin  itself.  Ballantyne  is  in  favor  of  doing 
away  with  all  our  present  views,  believing  that  the  mutilation  takes  place  in  the 
embryonal  period. 

12.  Fetal  Neoplasms. — Affections  of  this  class  are  embryonal  in  origin,  and 
hence  to  be  ranked  with  anomalies  and  monstrosities.  The  fetal  tissues  may  be 
the  seat  of  cysts,  fibromata,  chondromata,  lymphangiomata,  exostoses,  rhabdo- 
myomata,  sarcomata,  etc. 

13.  General  Fetal  (Edema. — Anasarca. — This  is  a  total  dropsical  condition 
of  the  fetus,  including  complete  anasarca  and  effusion  into  all  the  serous  sacs, 
the  placenta  being  often  oedematous  (Fig.  440).  This  affection  is  extremely 
rare.  Ballantyne  could  find  but  60  cases  recorded  in  literature.  This  number, 
however,  does  not  include  cases  of  dropsical  double  monsters.  There  is  sufficient 
evidence  in  some  cases  to  connect  the  fetal  oedema  with  developmental  anomalies 
of  the  fetal  circulation,  or  perhaps  with  certain  visceral  inflammations  in  the  fetus. 
The  behavior  of  the  fetus  during  gestation  presents  no  peculiarities.  Diagnosis 
during  labor  is  likewise  difficult.  Dystocia  after  birth  of  the  head  might  suggest 
dropsy  of  the  trunk,  but  delay  at  this  period  of  labor  might  be  due  to  many  other 
causes,  which  would  have  to  be  excluded  in  diagnosis,  A  fetus  has  never  yet  sur- 
vived the  disease. 

General  Fetal  (Edema  in  Twin  Monstrosities. — There  are,  according  to 
Ballantyne,  no  cases  on  record  in  which  both  twin  fetuses,  whether  normal  or 
monstrous,  were  afflicted  with  general  dropsy;  and  but  two  cases  are  known  to 
have  existed  in  which  one  of  the  normal  twins  has  thus  suffered  (Fig.  441). 

14.  Maternal  Traumatisms. — The  fetus  may  be  seriously  or  fatally  injured  by 
external  violence.  This  has  already  been  noted  in  the  section  on  injuries  of  the 
fetus  due  to  external  violence  (page  269). 

15.  Maternal  Uterine  Disease  Affecting  the  Fetus. — Chronic  metritis  and 
endometritis  have  been  noted  as  causes  of  fetal  death.     Hirst  reports  two  cases 


ANTENATAL  DISEASES  OF   THE  FETUS. 


271 


in  which  non-development  of  the  uterus  was  apparently  the  cause  of  repeated 
premature  deliveries.  Prolapse  of  the  gravid  uterus  may  exist.  This  is  not 
often  primary  in  pregnancy,  and  if  the  organ  does  not  rise  in  the  pelvis  it  will, 
especially  if  the  pelvis  is  smalt,  become  jammed  in  by  the  bony  parietes  and  abor- 
tion occur.  Anteversion  of  the  pregnant  uterus  is  not  often  attended  with  serious 
symptoms,  but  retrodisplacement  of  the  gravid  uterus  is  very  productive  of 
abortions.  The  influential  causes  are  metritis  and  endometritis,  hyperemia,  and 
hemorrhage  into  the  decidua  which  result  from  the  venous  stasis  caused  by  the 
retro-displacement. 

i6.  Fever  in  the  Mother  Affecting  the  Fetus.— This  is  a  common  cause  of 

abortion  and  premature  deHvery,  especially 
when  fever  is  suddenly  developed.  Many  ex- 
periments have  been  made  on  animals  in  order 
to  arrive  at  the  definite  effects  that  high  tem- 
perature of  maternal  origin  produces  in  the 
fetus.  Views  on  the  subject  have  changed  to  a 
great  degree  accordingly.  It  has  been  shown  in 
the  guinea-pig,  for  example,  that  the  fetus  can 
endure  a  much  higher  temperature  than  had 
\  formerly  been  supposed.     In  one  case,  the  ani- 


FiG.  440. — General  CEdema   of 
THE  Fetus. — (BaUantyne.) 


Fig.  441. — General  CEdema  in  a  Twin  Fetus. —  (Bal- 
lantyne.) 


mal  after  attaining  a  temperature  of  111.2°  F.  (44°  C),  lived  nine  mmutes.* 
Danger  to  the  fetus  must  be  feared  only  when  the  maternal  temperature  rises 
suddenly  or  reaches  a  point  over  105°  F.  (40.5°  C).  In  the  latter  case  energetic 
antipyretic  measures  would  be  indicated.  In  case  of  maternal  death,  post- 
mortem Csesarean  section  or  accouchement  forc6  would  be  useless  if  the  patient  s 
temperature  had  reached  109^  F.  (43°  C.),  or  if  it  had  risen  with  great  rapidity. 
17.  Death  of  the  Mother  Affecting  the  Fetus.— The  effect  of  the  maternal 
death  upon  the  fetus  in  utero  is  considered  in  the  section  on  post-mortem  delivery 
(Part  V). 

*  Preyer:  "  Physiologic  des  Embryo,"  Leipzig,  1S84. 


272 


PATHOLOGICAL  PREGNANCY. 


VIII.  DEATH  OF  THE  FETUS. 

I.    Maceration.      2.  Mummification,      j.  Absorption.      4.  Putrefaction.      5.   Saponification. 

6.  Calcification. 

Etiology. — Successive  pregnancies  in  the  same  mother  may  result  in  still- 
births, or  in  the  birth  of  children  who  live  but  a  short  time.  Syphilis  in  one  of 
the  parents  is  thus  suggested,  and,  according  to  Ruge,  it  occurs  in  83  per  cent. 

of  the  cases.  Other  condi- 
tions, however,  may  pro- 
duce a  like  result.  Apo- 
plexy of  the  placenta, 
membranes,  or  ovum  itself, 
resulting  from  an  inflam- 
mation of  these  tissues,  is  a 
frequent  cause  of  fetal 
death.  Systemic  poisoning 
of  the  mother  with  lead, 
mercury,  or  tobacco  may 
result  fatally  to  the  fetus. 
Not  only  maternal  influences  are  to  be  considered  in  fetal  death,  but  paternal 
conditions  as  well  such  as  old  age,  extreme  youth,  alcoholism,  chronic  disease, 
etc.  Sometimes  no  apparent  cause  can  be  discovered,  and 
the  mother  seems  to  abort  simply  from  habit,  and  at  about 
the  same  period  in  her  pregnancies.  The  essential  cause  of 
this  catastrophe  may  be  in  the  fetus  itself,  from  diseases, 
injuries,  or  deformities.  The  effect  of  the  death  of  the 
fetus  on  the  mother  may  be  really  nil  unless  the  germs  of 
putrefaction  in  some  way  reach  the  body. 


Fig.  442. — Macerated  Fetus. — {M anhalian  Maternity.) 


Fig.  443. — Mummified  Fetus  and  Necrotic  Decidua.  The  fetus 
died  at  the  third  month,  but  the  entire  ovum  was  retained  for 
seven  months  more.  The  decidua  and  chorion  are  filled  with 
coagulated  hematomata.  The  fetus  measured  3-^  inches  (8  cm.) , 
was  much  deformed,  and  the  left  foot  was  adherent  to  the  right 
leg. — (Schaeffer.) 


Fig.  444.  —  Mummi- 
fication OF  THE 
Fetus. — (Galabin.) 


Diagnosis  of  Fetal  Death. — ( i )  The  uterus  ceases  to  grow  or  diminishes  in  size. 
(2)  Subjective  symptoms  of  pregnancy  gradually  disappear.  (3)  The  milk 
secretion  appears.     (4)  The  fetal  heart-sounds  and  movements  disappear.     (5) 


DEATH   OF  THE  FETUS. 


273 


There  are  loss  of  resiliency  and  crepitation  of  the  fetal  skull.  This  latter  occurs 
only  when  the  fetus  has  been  dead  for  some  time,  and  the  head  has  become 
quite  macerated,  so  that  the  bones  are  loosely  joined  together.  (6)  Peptonuria 
and  disturbance  of  renal  function  occur.  (7)  Diminution  of  cervical  temperature 
is  noted.  (8)  There  is  absence  of  pulsation  in  the  umbilical  cord,  or  in  the  fetal 
precordium,  which  may  be  learned  by  introducing  the  hand  within  the  uterus.  (9) 
Stoltz's  sign  is  not  positive,  but  is  supposed  by  him  to  consist  in  a  slight  mur- 
mur or  rustle,  which  is  caused  by  decomposition  of  the  amniotic  fluid.  (10) 
Certain  changes  in  the  health  or  the  condition  of  the  mother  have  been  supposed 
to  point  to  the  existence  within  her  uterus  of  a  dead  fetus,  such  as  depression  of 

spirits,  pallor  of  the  face,  a  feeling  of  weight 
.'^  in  the  lower  part   of  the  abdomen;    but 

^    ^  these  signs  are  uncertain.     The  health  of 

the  mother  is  not  affected,  so  long  as  the 

membranes  remain  unruptured.  \ 

Changes  in  the  Fetal  Structures. — The 

kind  of  change  that  will  take  place  in  the 


Fig.  445. — Foetus  Papyraceus. 
{Author's  case.) 


Fig.    446. 


-LiTHOPEDiON    ("Stone    Fetus"). 
{Ahlfeld.) 


fetus  depends  on  the  time  of  its  death,  the  length  of  time  from  that  event  until 
expulsion,  and  whether  or  not  there  will  be  access  of  air  to  the  amniotic  sac.  (i) 
Maceration  (Fig.  442) :  This  is  the  most  common  change  in  the  fetus  after  death. 
The  skin  loses  its  physiological  activity,  and,  as  a  result,  the  vemix  caseosa  is  no 
longer  secreted  for  the  protection  of  the  fetus,  and  the  liquor  amnii  produces 
maceration.  A  fetus  in  this  condition  is  known  as  a  jcctus  sanguinolentus.  The 
surface  is  likened  in  appearance  to  a  washerwoman's  hand,  wrinkled  and  softened. 
Here  and  there  the  epithelium  has  desquamated,  leaving  glistening  red  spots. 
All  of  the  tissues,  even  to  the  internal  organs,  are,  as  it  were,  water-logged.  The 
cord  lacks  the  normal  spiral  aspect,  being  round,  soft,  and  smooth.  The  amniotic 
fluid,  as  noted  under  that  heading,  is  much  discolored  from  the  absorption  of  the 
18 


274  PATHOLOGICAL  PREGNANCY. 

blood  coloring-matter  and  the  products  of  decomposition.  It  may  be  reddish, 
greenish,  or  brownish,  and  it  may  possess  an  offensive  odor.  (2)  Mummification 
(Figs.  443,  444,  44S):  This  change  sometimes  occurs  after  a  missed  labor.  It 
may  be  regarded  as  typical  in  a  dead  fetus  which  has  attained  the  age  of  several 
months,  but  can  occur  only  when  the  membranes  have  remained  unruptured. 
If  the  fetus  has  for  some  time  been  subjected  to  pressure,  as  in  the  case  of  twins 
when  the  live  embryo  by  its  growth  gradually  compresses  the  dead  one,  the  latter 
will  finally  become  very  fiat,  and  is  then  known  as  foetus  papyraceus  (Fig.  445)- 
This  process  of  mummification  has  been  rightly  named,  for  such  a  fetus  is  dry 
and  shriveled  in  appearance.  The  color  is  grayish-yellow,  and  the  consistency 
is  leathery.  The  amniotic  fluid,  which  is  lacking,  has  either  been  absorbed  by 
the  chorion  or  drained  off,  consequently  the  fetal  appendages  are  likewise  dried 
and  tough,  and  show  some  fatty  degeneration.  This  condition  is  frequently 
caused  by  the  twisting  of  the  cord  around  the  neck  of  the  fetus.  (3)  Absorption  : 
Total  absorption  can  occur  only  in  the  first  ten  or  twelve  weeks  of  pregnancy. 
It  has  occurred  in  intrauterine  pregnancy,  and  is*  a  favorable  termination  in  ex- 
trauterine pregnancy.  The  first  step  in  this  process  is  maceration  of  the  fetus, 
followed  by  a  complete  absorption.  The  striking  characteristic  is  the  thick  and 
mucilaginous  condition  of  the  liquor  amnii.  (4)  Putrefaction  :  So  long  as  the 
membranes  remain  intact,  putrefaction  is  impossible.  Physometra  and  tym- 
panites uteri  may  subsequently  occur  as  the  result  of  this  transformation.  In 
this  process  the  soft  parts  are  disintegrated,  leaving  the  bones  to  be  disposed  of. 
either  by  ulcerating  their  way  through  the  overlying  structures,  or  by  surgical 
removal.  It  is  not  uncommon  to  find  suppuration  coincident  with  putrefaction. 
(5)  Saponification :  Saponification  and  adipoceration  are  parts  of  some  chemical 
change,  by  which  the  fetus  becomes  fatty  or  soapy,  through  the  deposit  within 
its  tissues  of  margarates  of  calcium,  potassium,  cholesterin,  and  sodium.  After 
this  transformation  it  has  a  characteristic  greasy  feel.  (6)  Calcification  (Fig. 
446) :  This  change  may  occur  as  an  intrauterine  or  extrauterine  termination  of 
pregnancy,  when  a  lithopedion  is  formed.  The  process  consists  of  the  deposition 
of  lime  salts  in  the  fetal  tissues,  the  result  being  what  is  known  also  as  a  "  stone 
child."  There  are  recorded  cases  in  which  this  condition  has  been  shown  to  exist 
for  years,  the  petrified  fetus  being  retained  in  utero. 


IX.   DISEASES  OF  THE  GENITAL  ORGANS. 

/.  Anteflexion  and  Anteversion.  2.  Retroflexion,  Retroversion,  and  Incarceration.  5.  Latero- 
flexion  and  Later  aversion.  4.  Prolapse  of  the  Pregnant  Uterus.  5.  Torsion.  6.  Hernial 
Protrusion  of  the  Pregnant  Uterus.  7.  Periuterine  Inflammation  and  Adhesion.  8.  Rheu- 
matism of  the  Uterine  Muscle,  g.  Metritis.  10.  New  Growths  in  the  Uterus.  11.  Spon- 
taneous Rupture.  12.  Malformations,  ij.  Leucorrhea.  14.  Cystic  Vaginitis.  15.  Specific 
Vaginitis.  16.  Prolapse  of  the  Vagina,  ly.  Pruritus  Vulvae.  18.  Varicosities  of  Vagina 
and  Vulva,  ig.  Vegetations.  20.  CEdema  of  the  Vulva.  21.  Eczema  of  the  Nipple.  22. 
Mammary  Abscess.     2j.  Hemorrhage  from  the  Genitals  during  Pregnancy. 

I.  Anteflexion  and  Anteversion  (Fig.  151). — In  the  later  months  of  pregnancy, 
owing,  in  multigravidae,  to  the  lax  condition  of  the  abdominal  walls,  or  to  the  sepa- 
ration of  the  recti,  or  to  the  giving  way  of  an  old  cicatrix,  anteflexion  and  ante- 
version may  occur,  giving  rise  to  the  condition  known  as  pendulous  abdomen, 
or  "  hanging  belly."  This  condition  is  also  a  frequent  accompaniment  of  pelvic 
deformities,  due  to  the  fact  that  the  uterus  cannot  descend,  as  in  normal  preg- 
nancy.    The  fundus,  under  such  circumstances,  may  be  lower  than  the  cervix, 


DISEASES  OF  THE  GENITAL  ORGANS. 


275 


the  latter  being  carried  upward  and  backward  into  the  hollow  of  the  sacrum; 
thus  labor  may  be  greatly  complicated,  and  the  presenting  part  be  directed 
away  from  the  axis  of  the  pelvic  outlet.  Incarceration  of  an  antefiexed,  pregnant 
uterus,  although  rare,  has  been  known  to  occur,  as  the  result  of  an  inflammatory 
adhesion,  or  after  the  operation  of  anterior  fixation  or  suspensio  uteri.  In  these 
cases  there  are  usually  severe  vesical  symptoms,  and  interruption  of  pregnancy, 
or  the  uterus  goes  to  term  and  operative  procedures  are  necessary  to  deliver  the 
fetus  from  the  uterus,  which  has,  so  to  speak,  buckled  upon  itself.  (See  Maternal 
Dystocia,  Part  V.)  As  a  general  rule,  the  uterus  replaces  itself  spontaneously 
bv  its  own  growth.  In  may  be  bound  down  by  adhesive  bands,  resulting  from 
inflammation,  in  which  case  pain  and  difficult  micturition  supervene.  The  organ 
then  either  forces  itself  upward  into  the  abdomen  or  expels  its  contents.  If 
there  are  no  pelvic  tumor,  no  exudate,  and  no  previous  anterior  displacement  to 
account  for  the  pathological  position,  then  its  cause  will  probably  be  found  in  a 
contracted  pelvis,  or  in  retraction  of  the  utero-sacral  ligaments.  This  condition  is 
also  accentuated  by  the  intra-abdominal  pressure  brought  to  bear  on  the  posterior 
uterine  wall.     In  rare  cases  traumatism  may  cause  acute  anterior  displacement. 


An/,  aid.  tfolt  — 

Anl.Per./kt.  — 

Pariefal PerUoneum 


Vessels  ofClilirrts  '  - 
l/relhra  — 
Lfficujih  minus 
Triifon  efBladdei — 
Voffina  — 
Perineumr 
jpkincter  am.  exlernus 
Jphiitiler  cuu  inlerruis 


UmhilLcus 

Left  Com.ii.tui. 

^Left  Com.il:yein 
I/orn  of ///eras 
,  (/ferine porf of rf.ful/e 
_  C'feruie yes. pouch 
_  Uterin£  yessels 
Peu^fas pouch 
^^U  fffero  satral 
fi^ameni 


Fig.  447. 


-Enormous  Distention  of  the  Bladder,  Rectum,  and  Sigmoid  Flexure, 
CAUSING  Posterior  Displacement  of  the  Uterus. 


A  few  believe  in  the  causal  relationship  of  anterior  displacements  to  the  per- 
nicious vomiting  of  pregnancy,  but  this  I  have  failed  to  confirm.  This  malpo- 
sition often  causes  sterility,  but  seldom  has  any  relation  to  abortion.  Symp- 
toms: In  extreme  cases  of  this  condition,  shoulder  presentations  of  the  fetus  must 
be  looked  for,  and  there  will  be  pain  in  the  distended  skin,  oedema  of  the  lower 
abdomen,  vesical  and  rectal  disorders,  while  locomotion  will  often  be  accom- 
plished with  great  difficulty.  Treatment:  In  the  simple  and  non-adherent  cases, 
which  occur  in  the  early  months  of  pregnancy,  it  will  usually  be  sufficient  to 
regulate  the  bowels  and  to  keep  the  patient  in  the  recumbent  posture  for  the 
greater  portion  of  the  time.  In  case  of  pendulous  abdomen  the  uterus  should  be 
replaced  and  retained  by  a  moderately  firm  bandage  (Figs.  228  and  229).  In 
the  adherent  or  incarcerated  cases  an  effort  should  be  made,  under  etherization, 
with  careful  manipulation,  to  break  down  the  bands  of  adhesion;  if  this  fails  and 
no  marked  symptoms  are  present,  the  case  may  be  allowed  to  proceed  as  far 
toward  term  as  possible.  I  delivered  one  child  by  version  at  term  from  such 
an  adherent  uterus,  the  result  of  anterior  fixation  for  retroflexion. 

2.  Retroversion  and  Retroflexion   (Figs.  447  to  451). — Retroversion  is  the 


276 


PATHOLOGICAL    PREGNANCY. 


/ 


Fig.  448. — Retroflexion  and  Prolapse  of  the  Preg- 
nant Uterus.  Danger  of  sloughing  into  the  poster- 
ior vaginal  wall,  the  anterior  rectal  wall,  or  through 
the  perineum. 


most  important  of  the  uterine  displacements,  on  account    of   the    serious    re- 
sults which  sometimes  follow  it.     It  is  a  cause  of  sterility,  and  if  conception 

does  take  place,  the  malposi- 
tion generally  corrects  itself 
"^^-..^J  by  the  end   of  the   third  or 

fourth  month.  At  times 
abortion  occurs.  In  multi- 
gravidas  retroflexion  is  one 
of  the  commonest  displace- 
ments, but  it  rarely  causes 
sterility. 

Etiology. — Backward  dis- 
placements may  be  caused  by 
previous  uterine  disease;  e.  g., 
adhesions  between  the  uterus 
and  posterior  wall  of  the  pel- 
vis, or  by  relaxation  of  the 
round  ligaments.  It  may  also 
be  produced  by  falls  or  violent 
jars;  distention  of  the  blad- 
der may  be  regarded  as  a  pre- 
disposing cause.  It  is  more 
likely  to  occur  in  cases  of  flat- 
tened pelvis. 

Symptoms. — Vesical  irri- 
tation from  pressure  of  the 
cervix  upon  the  bladder,  constipation  and  pain  in  the  back  from  pressure  of  the 
fundus,  sensations  of  pressure  and  weight  in  the  pelvis,  are  the  prominent  symp- 
toms, which  generally  come 
on  gradually,  rarely  sud- 
denly. Locomotion  is  some- 
times very  difficult ;  there  are 
frequent  reflex  phenomena, 
vomiting  holding  a  promi- 
nent place.  On  examina- 
tion, the  cervix  is  found  ele- 
vated, the  body  of  the  uterus 
is  in  the  cul-de-sac  of  Doug- 
las, the  anterior  vaginal  for- 
nix is  empty,  and  the  blad- 
der is  displaced  downward 
and  backward. 

Terminations. — By  the 
end  of  the  third  month,  re- 
troversion usually  disap- 
pears with  the  upward 
growth  incident  to  preg- 
nancy, by  (i)  spontaneous 
reposition.     When  this  does 

not  occur,  however,  and  when  the  ftmdus  remains  posterior,  the  increase  in  size 

of  the  uterus  causes   an  aggravation  of  all  the  symptoms,  and  if  the  upward 

*  "Arch.  f.  Gyn.,"  Bd.  xli,  Taf.  viii.  Fig.  i 


Fig.  449. — Sagittal  Section  of  a  Retroflexed  In- 
carcerated Pregnant  Uterus  at  Five  and  a  Half 
Months.  Necrosis  of  the  Bladder  and  Death  Re- 
sulted.—  {Schwryzer.  *) 


DISEASES  OF  THE  GENITAL  ORGANS. 


277 


growth  and  ascent  of  the  uterus  are  prevented  by  the  promontory  of  the  sacrum, 
the  condition  is  known  as  (2)  incarceration.  (3)  Spontaneous  abortion  or  mis- 
carriage is  another  termination,  Caused  by  uterine  congestion  and  interference 
with  the  growth  of  the  fetus. 

Incarceration  (Figs.  449,  450,  451). — By  incarceration  is  meant  the  reten- 
tion of  the  uterus  below  the  promontory  of  the  sacrum  and  in  the  true  pelvis. 
If  the  retroflexed  or  retroverted  uterus  is  not  replaced,  or  if  spontaneous 
reposition  or  abortion  does  not  occur,  the  increasing  size  of  the  uterus  results 
in  its  farm  impaction  in  the  pelvis.  The  symptoms  are  vesical  irritation  and  pain 
in  the  back,  retention  of  urine  from  pressure  upon  the  bladder  and  obstinate 
constipation,  or  even  obstipation,  from  pressure  of  the  fundus.  The  genitals 
and  thighs  may  become  swollen  and  oedematous,  and  grave  symptoms,  the  re- 
sult of  peritonitis,  due  to  rupture  of  the  bladder  or  to  sloughing  of  the  uterus  or 
to  severe  metritis  or  parametritis,  may  ensue.  Abdominal  palpation  fails  to 
disclose  the  fundus,  while  vaginal  ex- 
amination shows  that  the  latter  is  im-  ^^ ^^_^ 

prisoned  in  the  cul-de-sac  of  Douglas. 
The  latter  fact  may  be  made  plainer  by 
examination  per  rectum.  The  cervix 
may  be  found  behind  the  symphysis, 
or  it  may  be  difficult  or  impossible  to 
reach  it.  There  maybe  great  disten- 
tion of  the  bladder,  and  the  perineum 
may  even  be  distended  by  the  pressure 
of  the  fundus. 

Diagnosis. — Incarceration ,  especi- 
ally in  its  early  stages,  may  be  con- 
founded with  extrauterine  pregnancy. 
In  the  latter  condition,  however,  though 
the  uterus  may  be  somewhat  enlarged, 
the  normal  relations  of  the  cervix  and 
fundus  are  still  preserved;  distention 
of  the  bladder  does  not  usually  occur, 
nor  is  there  oedema  of  the  vulva,  or 
perineal  distention,  or  severe  symptoms 
of  pelvic  congestion.  The  rupture  of 
the  sac  in  extrauterine  pregnancy  usu- 
ally occurs  near  the  end  of  the  second  month,  while  incarceration  usually  develops 
during  the  fourth  month.  In  cases  of  incarceration  uterine  contractions  may  be 
recognized  in  the  tumor.  In  doubtful  cases  examination  under  anesthesia,  with  the 
bladder  empty,  will  be  necessary.  There  is  often  dribbling  of  urine  at  the  third  or 
fourth  month.  Menorrhagia  would  differentiate  this  condition  from  intrauterine 
polyp.  As  to  the  terminations,  if  the  incarceration  is  not  relieved,  there  may  be 
rupture  of  the  posterior  vaginal  wall  and  perineum,  with  extrusion  of  the  uterus ; 
very  rarely  pregnancy  has  continued  to  term,  the  anterior  wall  of  the  uterus 
becoming  enormously  stretched,  and  the  head  of  the  fetus  remaining  in  the  hollow 
of  the  sacrum.  Sloughing  of  the  uterus  may  occur,  with  the  discharge  of  its 
contents  into  the  vagina  or  rectum. 

Prognosis. — In  the  lesser  forms  of  displacement,  occurring  early  in  pregnancy 
the  prognosis  is  good,  since  spontaneous  replacement  usually  occurs.  Even  in 
cases  of  incarceration  the  prognosis  is  good  if  the  condition  is  promptly  and 
properly  treated.     In  neglected  cases,  however,  it  is  very  bad,  since  the  patient 


Fig.  450. — Partial  Retroflexion.  The 
posterior  uterine  wall  is  fixed  in  the  pelvic 
cavity.  The  anterior  wall  dilates  and  the 
dotted  lines  show  the  progressive  dilatation 
of  the  anterior  uterine  wall. — (Bumm.) 


278 


PATHOLOGICAL  PREGNANCY. 


is  exposed  to  many  dangers,  including  rupture  of  the  bladder,  sloughing  of  the 
uterus,  septic  peritonitis,  shock,  and  exhaustion. 

Treatment. — The  bladder  and  bowels  being  emptied,  in  the  simpler  forms  of 
displacement  an  effort  may  be  made  to  replace  the  uterus  by  pressure  with  the 
fingers  while  the  patient  is  in  the  lithotomy  position ;  but  reduction  will  be  more 
easily  effected  if  the  patient  is  in  the  knee-chest  position.  (See  Operations 
Part  X.)  A  repositor  may  be  used  if  failure  attends  the  attempt  with  the  fingers, 
and  pressure  should  be  made  in  the  upward  direction  and  to  one  side,  in  order  to 
avoid  the  promontory.  The  reduction  will  be  more  easily  accomplished  if  the 
cervix  is  at  the  same  time  drawn  downward  by  a  volsellum  forceps  (Fig.  463). 
After  replacement,  the  newly  acquired  position  of  the  uterus  should  be  main- 
tained by  a  pessary  or  tampon,  large  enough  to  be  efficient.  If  the  uterus  is 
strongly  bound  down  by  adhesions,  steady  and  long-continued  pressure  should 
be  kept  up,  by  thoroughly  tamponing  the  posterior  cul-de-sac  through  a  Sims 
speculum,  with  the  patient  in  the  knee-chest  position,  the  boro-glyceride  tam- 
pons being  renewed  daily;  if  this  fails 
abortion  should  be  induced  before  incar- 
ceration takes  place.  I  have  seen  the 
insertion  into  the  vagina  of  a  rubber  bag, 
filled  with  water  and  kept  in  place  with 
a  T-bandage,  act  well  in  cases  not  of  long 
standing.  This  gentle,  continuous  pres- 
sure is  very  efficacious.  After  reduction, 
it  will  be  well  to  apply  a  large-sized 
Hodge  pessary.  When  reposition  is 
once  well  effected,  there  is  not  much 
danger  of  a  relapse. 

Treatment  after  Incarceration  Has  Oc- 
curred.— Strict  asepsis  should  be  ob- 
served, and  the  bowels  and  bladder 
emptied.  Considerable  difficulty  may  be 
experienced  in  passing  a  catheter,  owing 
to  the  height  of  the  bladder  and  the  com- 
pression of  its  lower  part ;  a  prostatic  or 
gum-elastic  catheter  should  be  tried.  By 
drawing  down  the  cervix  by  a  vulsellum 
forceps,  the  passage  of  the  catheter  will 
be  facilitated.  If  skilful  and  careful 
efforts  to  pass  the  catheter  are  not  successful,  the  bladder  must  be  aspirated  with 
rigid  asepsis,  about  two  inches  above  the  symphysis.  Efforts  at  reduction  are 
then  instituted  under  anesthesia,  and,  if  not  successful,  the  induction  of  abortion 
will  be  the  last  resort.  If  the  cervix  cannot  be  reached  by  drawing  it  down  with 
vulsellum  forceps,  it  will  be  necessary  to  aspirate  the  uterus  through  the  posterior 
vaginal  cul-de-sac.  The  most  prominent  part  should  be  selected,  and  as  soon  as 
the  bulk  of  the  uterus  has  been  sufficiently  reduced  by  the  discharge  of  the  liquor 
amnii,  the  organ  should  be  replaced,  the  cervix  seized,  the  os  dilated,  and  the 
uterus  emptied  in  the  usual  manner.  In  rare  cases  the  induction  of  abortion 
may  be  impossible,  and  vaginal  hysterectomy  will  be  necessary,  especially  if 
sloughing  of  the  uterus  have  occurred. 

3.  Latero-version  and  Latero-flexion. — These  are  not  very  frequent,  and  are 
usually  due  to  some  malformation.  A  moderate  deviation  to  the  right  is  a 
normal  condition,  constituting  the  right  lateral  obliquity  of  the  pregnant  uterus. 


Fig.  451. — -Reduction  of  an  Incarcer- 
ated Retroflexed  Pregnant  Uterus 
BY  Means  of  Fundal  Pressure,  Trac- 
tion ON  the  Cervix,  and  the  Knee- 
chest  Posture. —  {Bumm.) 


DISEASES  OF  THE  GENITAL  ORGANS. 


279 


In  rare  cases  the  uterus  is  deviated  laterally,  owing  to  a  congenital  shortening  of 
one  of  the  broad  ligaments.  Again,  there  may  be  a  defective  development  of 
one  side  of  the  uterus,  causing 

latero-fiexion.     Excessive    lat-  

eral  deviation  sometimes  oc- 
curs in  cases  of  pelvic  deform- 
ity. (See  Pelvic  Deformity, 
Part  V.)  The  effects  of  these 
malpositions  are  more  striking 
in  labor  than  in  pregnancy. 
(See  Maternal  Dystocia.) 

4.  Prolapse  oif  the  Pregnant 
Uterus  (Fig.  452). — This  is  an 
uncommon  occurrence,  and  in 
most  cases  the  prolapse  ante- 
dates the  conception.  It  may, 
however,  occur  during  preg- 
nancy, either  as  a  result  of  a 
severe  shock  or  fall,  or  from  a 
lax  condition  of  the  pelvic  floor, 
due  to  an  old  laceration  of  the 
perineum.  It  may  be  caused 
by  retroversion,  and  it  is  al- 
most without  exception  found 
in  multigravidas.  There  is 
probably  no  case  on  record  in 

which  pregnancy  continued  till  term  in  a  uterus  outside  the  vagina.  In  the  cases 
reported  the  condition  was  probably  one  of  hypertrophic  elongation  of  the  infra- 


FiG.  452. — Total  Prolapse  of  a  Retroflexed 
Pregnant  Uterus,  Due  to  Pressure  of  a  Large 
Pedunculated  Ovarian  Cyst  on  the  Left  Side, 
Completely  Filling  in  the  True  Pelvis,  and 
Reaching  to  the  Umbilicus.  Rectocele  and 
Ischuria. — (Schaeffer.) 


H 


Fig.  453. — Labial  Hernia  of  the  Pregnant  Horn  of  a  Uterus  Bicornis. — (Winckel- 

Eisenhart.) 


vaginal  portion  of  the  cervix,  the  fundus  of  the  uterus  being  in  the  pelvis.     Hy- 
pertrophy of  the  supravaginal  or  infravaginal  portion  of  the  cervix  simulates 


280 


PATHOLOGICAL  PREGNANCY. 


procidentia,  and  if  amputation  of  the  hypertrophied  cervix  is  performed  during 
the  third  month,  pregnancy  may  continue  without  disturbance;  in  aggravated 
cases  this  treatment  is  indicated.  Terminations:  Spontaneous  reduction  usually 
takes  place,  in  consequence  of  the  upward  uterine  growth  incident  to  pregnancy; 
in  rare  cases  incarceration  may  occur,  producing  pain,  pressure  symptoms,  con- 
gestion, and,  if  not  reheved  abortion.  Diagnosis:  It  has  been  confounded  with 
cervical  hypertrophy,  and  this  mistake  should  be  avoided,  lest  it  lead  to  efforts 
at  reposition,  which  may  result  in  abortion.  A  careful  bimanual  examination, 
with  the  recognition  of  the  body  of  the  uterus  in  its  normal  position,  should  pre- 
vent this  mistake.  Treatment:  The  bladder  and  bowels  should  be  watched,  and 
the  patient  should  spend  much  of  her  time  in  the  recumbent  position  with  the 
hips  elevated,  and  standing,  walking,  and  lifting  should  be  avoided.  When  the 
prolapse  is  considerable,  the  uterus  should  be  replaced  and  kept  in  position  bv 


Fig.  454. — Hernia  of  the  Pregnant  Uterus. — {Adams.) 


an  air  or  water  pessary  and  a  vulvar  napkin  if  required.  When  incarceration  has 
occurred,  the  attempt  at  replacement  should  be  made  with  the  bowels  and  bladder 
empty.  As  a  preliminary,  the  patient  should  be  placed  upon  the  back  with  the 
hips  elevated,  and  the  congestion  of  the  uterus  diminished  by  scarification.  The 
knee-chest  position  may  be  of  service,  and  anesthesia  will  be  necessary.  If 
replacement  cannot  be  effected,  the  induction  of  abortion  is  indicated.  After 
labor  prolonged  rest  should  be  enjoined,  with  the  hope  that  involution  of  the 
organ  may  result  in  cure  of  the  prolapse.  There  is  always  a  possibility  that 
pregnancy,  labor,  and  the  puerperium  will  be  followed  by  the  cure  of  old  dis- 
placements. 

5.  Torsion. — In  some  cases  the  shght  normal  twisting  of  the  uterus  on  its 
long  axis  from  left  to  right  is  much  exaggerated,  or  it  may  be  reversed  and  the 
uterus  twisted  to  the  left.  This  condition  is  usually  due  to  adhesions,  the 
result  of  inflammatory  processes,  and  in  these  an  ovary  being  brought  forward, 


DISEASES  OF   THE  GENITAL  ORGANS. 


281 


may  be  injured  by  attempts  to  express  the  placenta  or  by  manipulation.     I  have 
never  observed  a  malpresentation  or  malposition  caused  by  excessive  torsion. 

6.  Hernial  Protrusion  of  the  Pregnant  Uterus  (Figs.  453,  454). — A  uterine  pro- 
trusion may  complicate  inguinal,  umbilical,  or  ventral  hernia,  and  when  it  occurs 
in  ventral  hernia  it  is  usually  due  to  separation  of  the  recti.  It  is  sometimes  seen, 
however,  on  the  side  of  the  abdomen,  and  may  be  due  to  congenital  defects  or  to 
an  operation  cicatrix.  Cases  of  inguinal  protrusion  sometimes  occur,  in  cases  of 
pregnancy,  in  one  horn  of  a  bicornate  uterus.  The  protrusion  of  the  pregnant 
uterus  in  femoral  hernia  is  denied  by  some  writers,  but  its  existence  has  been 
asserted  by  others;  e.  g.,  Spiegelberg.  Sometimes  adhesions  between  the  uterus 
and  intestine  cause  the  former  to  be  drawn  into  the  hernial  sac.  There  may  be 
hernia  of  the  ovary,  followed  by  hernia  of  the  uterus.  The  symptoms  in  case  of 
the  ventral  variety  are  not  import- 
ant, and  they  are   easily  mitigated.  .^-- 

Not  so  in  the  inguinal  variety,  for 
then  incarceration  and  strangulation 
rapidly  develop.  The  prognosis  is 
good  in  the  ventral  form,  but  grave 
in  the  inguinal.  The  diagnosis  of  a 
ventral  hernia  will  be  readily  appre- 
ciated, and  an  inguinal  or  a  femoral 
hernia  will  present  the  symptoms  of 
hernia,  with  the  absence  of  the  uter- 
us from  its  normal  position,  and  de- 
viation of  the  vagina  toward  the  side 
on  which  the  hernia  is  situated. 
Treatment:  In  the  case  of  a  ventral 
or  umbilical  hernia  the  treatment 
consists  in  reduction  and  an  ab- 
dominal supporter;  in  the  other 
varieties  reduction  should  be  effected 
if  possible,  and  maintained  by  a 
truss,  by  the  recumbent  position, 
and  by  the  avoidance  of  standing, 
walking,  and  heavy  lifting.  In  ad- 
vanced cases  reduction  may  not  be 
possible,  even  with  herniotomy,  and 
the  induction  of  abortion  or  hyster- 
ectomy may  be  necessary  as  a  last 
resort. 

7.  Peri-uterine  Inflammation  and  Adhesion. — These  affections  are  often  alle- 
viated by  appropriate  treatment,  which  should  be  employed  during  the  intervals 
between  pregnancies  (Fig.  455).  Sudden  rupture  of  adhesions  of  the  omentum 
and  its  contained  blood-vessels  during  the  onset  of  labor  may  cause  fatal  hemor- 
rhage into  the  peritoneal  cavity. 

8.  Rheumatism  of  the  Uterine  Muscle. — This  is  a  rare  condition.  There  is 
pain  of  a  neuralgic  or  a  myalgic  character,  much  aggravated  by  the  intermittent 
uterine  contractions  which  normally  occur  during  pregnancy.  It  is  observed  in 
patients  of  the  rheumatic  diathesis,  but  may  be  due  to  exposure  to  cold  and 
perhaps  to  violent  coughing  or  straining  efforts.  Treatment  consists  in  anodyne 
local  applications,  with  anodynes  and  salicylates  internally. 

9.  Metritis. — When  this  occurs  it  is  usually  an  aggravation  of  a  previously 


Fig.  455.— Periuterine  Inflammation  and 
Adhesion;  Tubal  Pregnancy;  Rupture  of 
THE  Sac;  Internal  Hemorrhage;  Numer- 
ous Cord-like  Adhesions  between  the 
Uterus,  Left  Tube,  and  Intestines. — 
{Hojmann.) 


282  PATHOLOGICAL  PREGNANCY. 

existing  condition,  and  thus  the  symptoms  of  the  pre-existing  disease  are  all  inten- 
l^ified  by  the  physiological  hypertrophy  of  pregnancy.  It  is  one  of  the  causes  of 
the  pernicious  vomiting  of  pregnancy.  Severe  pain  and  the  feeling  of  weight  and 
pressure  or  "bearing-down  feelings  "  in  the  pelvis  are  common;  abortion  often 
results.  Treatment:  Boro-glyceride  tampons  may  be  used,  but  if  long  con- 
tinued are,  of  course,  likely  to  induce  abortion;  anodynes  are  indicated;  ex- 
treme danger  for  the  mother,  especially  from  vomiting,  may  require  the  induc- 
tion of  abortion. 

io.  New  Growths. — Pregnancy  may  be  complicated  by  the  presence  of  various 
neoplasms  of  the  uterus,  especially  fibroid  or  fibro-cystic  tumors.  These  do  little 
harm  during  pregnancy,  as 'a  rule,  but  symptoms  of  pelvic  congestion  are  marked^ 
often  with  pain,  and  their  growth  is  rapid  by  reason  of  the  increased  vascularity 
of  pregnancy.  In  rare  cases  operative  interference  may  be  necessary,  on  account 
of  hemorrhage  or  excessive  distention.  As  a  complication  in  labor,  the  situation 
above  or  below  the  pelvic  outlet,  and  the  mobility  of  the  tumor,  will  be  important 
factors.  Malignant  growths  have  been  mentioned  in  connection  with  deciduoma 
malignum;  cancer  of  the  cervix  has  frequently  been  mistaken  for  placenta 
previa;  cystic  tumors  of  the  ovary  grow  very  rapidly  during  pregnancy.  New 
growths  are  far  more  important  as  a.  complication  of  labor  than  of  pregnancy. 
(See  Part  V.)  The  most  frequent  form  is  the  fibroid,  which  grows  rapidly  from 
the  increased  supply  of  blood  to  the  genitalia.  The  cervix  is  often  the  seat  of 
small  polypoid  growths  which  are  the  source  of  severe  hemorrhage.  Operations 
for  the  removal  of  new  growths  do  not  necessarily  interfere  with  pregnancy. 
(See  Operations  on  Pregnant  Women,  Part  X.) 

11.  Spontaneous  Rupture  of  the  Uterus. — This  is  a  rare  complication,  when 
occurring  in  pregnancy  independent  of  direct  traumatism.  It  may  occur  from 
excessive  distention;  from  multiple  pregnancy;  from  hydramnios  in  a  uterine 
wall  already  weakened  by  previous  prolonged  uterine  disease,  as  endometritis 
and  metritis,  malignant  disease,  a  previous  hysterectomy,  as  Caesarean  section, 
or  myomectomxy  for  fibroids.  It  has  occurred  in  the  interstitial  variety  of 
ectopic  gestation,  and  I  have  seen  a  case  of  partial  spontaneous  rupture,  follow- 
ing missed  labor,  in  a  case  of  pregnancy  in  one  side  of  a  uterus  septus.  The 
symptoms  are  the  same  as  those  of  rupture  during  labor;  e.  g.,  concealed  hem- 
orrhage and  shock.  The  prognosis  could  hardly  be  worse,  and  the  treatment  is 
the  same  as  for  a  ruptured  ectopic  sac;  hysterectomy  probably  gives  the  best 
prognosis,  although  suture  of  the  wound  may  be  employed. 

12.  Malformations  of  the  Genital  Organs. — (i)  Uterus. — These  are  caused, 
for  the  most  part,  by  the  preservation,  to  a  greater  or  less  extent,  of  the' septa 
between  the  ducts  of  Muller.  The  student  will  remember  that  from  the  upper 
portions  of  these  ducts,  as  they  converge,  are  formed  the  Fallopian  tubes,  and 
that  by  their  juxtaposition  and  the  absorption  of  their  inner  walls  the  uterus 
and  vagina  are  formed  (Fig.  460).  If  the  absorption  of  the  inner  walls  of  the 
tubes  does  not  take  place,  the  uterus  and  vagina  are  divided  into  two  lateral 
halves.  Should  a  partial  union  take  place,  a  corresponding  degree  of  malforma- 
tion results.  The  organ  resulting  from  this  faulty  development  may  present 
the  appearance  of  one  body  separated  into  two  parts  by  a  partition,  indicating 
that  the  two  Mullerian  ducts  have  become  joined,  but  that  the  partition  between 
them  has  persisted,  its  absorption  not  taking  place.  Or  there  may  be  two  more  or 
less  separate  bodies,  owing  to  the  non-union  of  the  ducts.  There  are  many  degrees 
of  these  deformities,  each  having  its  own  designation,  and  the  arbitrary  limits 
which  have  been  assigned  them  are  numerous.  However,  the  most  convenient 
nomenclature  would  seem  to  be  as  follows :  the  uterus  which  retains  its  original 


DISEASES  OF  THE  GENITAL   ORGANS.  ,283 

partition  is  known  as  uterus  septus  duplex.  The  partition  may  exist  in  approxi-  ■, 
mately  five  degrees.  The.  first  and  shghtest  degree  results  in  the  uterus  incudi-i^ 
formis  (Fig.  142)  (anvil-shaped  uterus),  the  organ  being  flattened  from  above 
downward,  and  its  transverse  diameter  being  longer  than  the  longitudinal. 
Another  slight  deformity  of  this  variety  is  the  uterus  cordiformis  (arcuate, 
cordate,  or  heart-shaped  uterus)  (Fig.  456);  here  the  original  embryonic  shape 
of  the  uterus  is  suggested  by  a  depression  in  the  median  line  of  the  fundus. 
This  condition  is  not  often  discovered  during  life,  although  digital  examination 
of  the  uterine  cavity  would  reveal  its  existence.  In  the  second  degree  the 
septum  extends  the  length  of  the  body  to  the  internal  os.  This  form  also  may 
escape  detection,  but  may  be  discovered  after  an  abortion  or  delivery,  and  it 
may  even  be  destroyed  by  pregnancy.  In  the  third  degree  the  septum  extends 
not  only  through  the  uterine  body,  but  also  through  the  cervix.  This  con- 
dition could  easily  be  recognized  by  careful  cervical  examination.  In  the 
fourth  degree  the  septum  runs  down  into  the  vagina,  but  does  not  completely 
divide  it.  In  the  fifth  degree  the  septum  divides  the  vagina  completely,  causing 
the  condition  known  as  vagina  septa,  or  double  vagina.  It  will  be  readily 
seen  that  different  degrees  of  persistence  of  the  septum  will  produce  correspond- 
ing kinds  of  malformation.  In  this  bifid  condition,  as  well  as  in  the  double 
uterus,  the  two  sides  may  be  equal  or  unequal. 

Double  Uterus  (Figs.  457,  460). — In  this  class  the  organ  is  more  or  less  com- 
pletely divided  into  two  distinct  parts.  In  the  first  degree  the  fundus  consists 
of  two  parts,  due  to  the  non-union  of  the  upper  parts  of  Muller's  ducts.  The 
external  surface  of  the  fundus  presents  a  depression  or  groove,  and  the  resulting 
form  is  called  the  uterus  bilocularis,  or  uterus  bicornis  arcuatus. 

Double  Uterus  Bicornis,  Uterus  Duplex  Bicornis  (Fig.  458). — When  the  ducts 
fail  to  unite  till  they  have  descended  for  some  distance  below  the  normal  point 
of  junction,  the  uterus  bicornis,  bicornate  or  bifid  uterus,  is  produced.  There  are 
two  diverging  uterine  cavities,  each  communicating  with  the  cervix  at  one  ex- 
tremity, and  with  a  Fallopian  tube  at  the  other.  The  cervix  in  this  form  may 
be  single  or  double.  When  there  are  two  vaginae,  one  of  them  may  have  a  blind 
ending  above  or  below. 

Uterus  Duplex  Separatus  cum  Vagina  Separata-  (Fig.  460). — In  the  uterus 
didelphys,  or  double  uterus,  we  have  a  rare  condition,  in  which  the  ducts  do  not 
unite  at  all,  and  consequently  there  are  two  separate  uterine  cavities  and  two 
vaginae;  each  body  has  its  tube  and  ovary.  This  is  a  retrograde  form  corre- 
sponding to  that  of  the  lowest  mammalia.  The  short  broad  ligament  connects 
the  diverging  bodies.  The  uterus  unicornis  results  from  the  faulty  development 
of  one  of  Muller's  ducts.  In  a  case  of  this  kind  one  tube  and  one  ovary  are  gen- 
erally lacking.  There  are  in  this  form  also  varying  degrees  of  development. 
There  may  be  a  rudimentary  horn,  or  it  may  be  sufficiently  developed  to  allow 
of  menstruation,  and  even  of  a  few  months'  pregnancy.  In  cases  in  which 
the  one  horn  is  entirely  lacking,  there  is  sometimes  discovered  the  absence  of  the 
kidney  and  ureter  on  the  malformed  side.  The  uterus  unicornis  may  possess  a 
double  cervix,  uterus  biforis. 

Absent  Uterus. — Diagnosis  of  this  extremely  rare  condition,  even  under 
narcosis,  is  never  positive.  Its  existence  is  nearly  always  coincident  with  the 
absence  of  the  entire  genital  system,  pre-eminently  the  vagina.  In  searching  for 
the  uterus,  which  is  not  palpable  by  the  ordinary  methods,  the  rectum  and 
bladder  may  be  explored  at  the  same  time,  the  former  by  the  index-finger  and 
the  latter  by  the  catheter.  Failure  to  outline  the  uterus  in  this  way  does  not 
offer  positive  evidence  of  its  absence,  since  it  may  be  placed  in  one  side  of  the 


284 


PATHOLOGICAL  PREGNANCY. 


pelvis,  or  it  may  be  in  such  a  rudimentary  condition  as  to  defy  discovery.     Celi- 
otomy or  necropsy  alone  will  prove  the  presence  or  absence  of  the  organ. 


Fig.  4=;6. — Pregnant  Uterus  Arcuatus, 
Transverse   Section. — (Bumm.) 


Fig.  457. — Uterus  Biseptus. 


Rudimentary  Uterus. — The  organ  may  be  represented  by  a  transverse 
bit  of  connective  tissue  attached  to  the  bladder,  and  divided  into  two  parts,  to 
each  'Of  which  is  attached  a  tiny  ovary. 
The  palpation  of  these  organs  is  rarely 
possible.     In  these  cases    the  vagina  is 


Fig.  458. — Bicornate  or  Bifid  Uterus. 


Fig.  459. — Uterus  Bipartitus  or 
Duplex. 


either   absent,  or  exists   in  such  a  stunted   condition,  with  a  hymen  so  very 
small,  that  the  internal  genitalia  are  often  thought  to  be  entirely  absent.     Some- 


DISEASES  OF  THE  GENITAL  ORGANS.  285 

times  the  vagina  is  represented  by  a  small  cul-de-sac  which  is  continuous  with 


Fig.  460. — Uterus  Didelphys  or  Double 
Uterus.  C,  Uterine  cavity;  V,  vagina. 
— (Dak  in.) 


Fig.  461. — Uterus  with  Two  Horns, 
One  Developed  and  the  Other  Ru- 
dimentary.— (Dakin.) 


the    urethra;    although    so    slightly    developed,   it    may    become   enlarged    on 

attempted  sexual  intercourse.  Men- 
struation is  rarely  present  in  these 
cases.  When  it  is,  it  may  be  so 
painful  as  to  indicate  castration. 
Hematometra  sometimes  occurs. 
Ovulation  may  take  place  without 
menstruation.  Ordinary  bimanual 
palpation,  or  the  method  mentioned 


Fig.  462. — Atresia  of  a  Rudimentary 
Horn  of  a  Double  Uterus  with  an 
Accumulation  of  Menstrual  Blood. 


Fig.  463. — Uterus  Septus.     C,  C,  Uter- 
ine cavities. — {Dakin.) 


Fig.  464. — Uterus  Unicornis. 


Fig.  465. — Uterus  with  Complete 
Absence  OF  One  Horn.  C,  Uter- 
ine cavity;   V,  vagina. — {Dakin.) 


under    absent    uterus,     may     detect    the     condition;    however,    with    a    well- 


286  PATHOLOGICAL  PREGNANCY. 

developed  vagina  and  established  menstruation  it  may  not  be  recognized.  The 
breasts  and  pubes  are  generally  well  formed.  When  Miiller's  ducts  are  in  a  very 
rudimentary  state,  the  ovaries  are  often  in  a  condition  of  cystic  degeneration. 

Fetal  and  Infantile  Uterus;  Pubescent  Uterus. — Hypoplasia  uteri  is  not  an 
atrophic  uterus  but  results  from  faulty  development.  The  fetal  uterus  presents 
the  characteristics  of  the  organ  as  found  in  the  fetus — a  very  small,  thin-walled, 
bullet-shaped  body,  with  a  cervix  several  times  its  length.  The  vagina  is,  as  a 
rule,  short  and  narrow.  The  patient  generally  suffers  from  extreme  chlorosis, 
amenorrhea  which  defies  treatment,  and  attendant  troubles.  The  infantile 
form  presents  the  normal  organ  in  miniature.  The  arbor  vitas  folds  do  not  reach 
to  the  fundus  in  this  form  as  they  do  in  the  fetal  form.  The  patient  is  troubled 
with  amenorrhea,  dysmenorrhea,  sterility,  and  nervous  symptoms.  Such  cases 
should  receive  systematic  treatment,  not  only  general  but  also  local.  The 
cervix  ought  to  be  dilated  and  the  body  subjected  to  intrauterine  faradism, 
as  well  as  medicinal  applications.  In  these  cases  the  vagina,  pubes,  and  mammae 
are  generally  perfectly  formed,  although  the  opposite  condition  may  obtain. 
Menstruation  is  not  often  present,  nor  is  sexual  desire. 

Imperforate  fetal  uterus  is  of  very  rare  occurrence.  The  body  especially  lacks 
a  cavity.  Uterus  fetalis  hicornis  is  an  organ  which  presents  the  fetal  character- 
istics in  both  form  and  size,  and  is  possessed  of  the  cornua. 

Accessory  uteri  have  been  noted.  In  one  case  a  somewhat  smaller  uterus,  in 
sagittal  position,  lay  in  front  of  the  normal  organ.  The  origin  of  this  anomaly  is 
not  clear.  Precocious  development  of  the  uterus,  with  that  of  the  other  genitalia, 
is  not  infrequently  observed  in  small  children.  Unusual  cases  have  been  de- 
scribed in  which  the  mucous  membrane  of  the  cervix  lies  in  transverse  folds. 
Transverse  septa  have  been  found  in  the  cervix.  Cases  are  noted  in  which 
these  septa  had  to  be  removed  before  labor  could  be  completed.  Several  con- 
genital anomalies  of  position  of  the  uterus  have  been  noted.  The  oblique  posi- 
tion of  the  organ,  in  which  the  body  is  bent  to  one  side  or  the  other  by  the  shorten- 
ing of  one  of  the  lateral  ligaments,  also  occurs. 

Congenital  retroflexion  exists  in  some  cases,  as  well  as  anteflexion  with  its 
attendant  symptoms,  dysmenorrhea,  nervous  disturbances,  etc. 

Congenital  prolapsus  uteri  is  rarely  met  with,  and  is  generally  only  one  of 
several  associated  stigmata  of  faulty  development. 

Not  alone  the  uterus  is  subject  to  malformations,  but  the  adnexa  and  external 
genitalia  as  well.  One  or  both  tubes  may  be  absent  or  rudimentary.  In  the 
former  instance  the  ovaries  and  uterus  are  apt  to  be  lacking  also.  In  certain 
cases  there  are  several  openings  to  the  tube  which  may  vary  in  their  position. 
The  tubes  may  also  present  abnormalities  in  length  or  calibre. 

(2)  Ovaries. — Absent  ovaries  constitutes  also  a  very  rare  condition,  which 
it  is  impossible  to  recognize  without  direct  inspection.  These  organs  may  be 
rudimentary,  or  one  alone  may  be  lacking,  as  in  uterus  unicornis.  The  absence 
may  be  only  apparent,  as  when  the  ovary  is  attached  to  one  of  the  other  abdom- 
inal organs.  Supernumerary,  as  well  as  accessory,  ovaries  have  been  reported, 
the  former  being  far  more  rare  than  the  latter.  Malposition  of  the  ovaries  is  not 
very  uncommon,  and  often  gives  rise  to  much  trouble.  In  case  of  the  presence 
of  a  hernia,  the  prolapsed  ovary  may  slip  into  the  hernial  sac,  and  cause  extreme 
pain,  while  the  diagnosis  of  the  condition  will  be  very  difficult  to  make. 

(3)  Ligaments. — The  uterine  ligaments  may  be  defective  or  absent.  This 
condition,  especially  of  the  round  ligament,  is  generally  associated  with  faulty 
development  of  the  uterus. 

(4)  Vagina. — The  vagina  may  be  absent  or  rudimentary.     When  absent,  the 


DISEASES  OF  THE  GENITAL  ORGANS.  287 

■uterus  will  also  generally  be  absent,  or,  if  present,  it  will  be  slightly  developed. 
If  only  a  part  of  the  vagina  is  present,  it  will  usually  be  the  lower  part.  At 
times  the  whole  vulva  may'  be'  absent  or  ill-formed.  There  are  all  sorts  and  de- 
grees of  deformities  of  the  vagina,  associated  with  a  variety  of  changes  of  physio- 
logical function  of  the  internal  genital  organs.  Indications  for  operative  treat- 
ment will  depend  greatly  on  the  conditions  of  the  whole  genital  system.  Atresia 
may  exist  at  any  place  in  the  genital  canal,  between  the  vulval  opening  and  the 
internal  os.  It  may  be  congenital  or  acquired.  Congenital  atresia  is  found,  as 
a  rule,  at  the  lower  end  of  the  vagina.  Atresia  of  the  cervix  is  seldom  complete, 
and  is  the  result  of  cicatricial  formation.  This  may  result  from  laceration  in 
labor,  or  rarely  there  may  be  a  condition  of  cervical  endometritis,  followed  by 
agglutination  of  the  lips  of  the  cervix.  Complete  atresia  of  the  vagina  is  always 
associated  with  malformation  of  the  other  genitalia.  Atresia  of  the  vulva  is  not 
infrequently  seen.  The  vulva  may  be  absent,  and  this  condition  is  usually  only 
one  feature  of  a  general  genital  deformity.  It  may  also  be  infantile  in  its  devel- 
opment, as  is  sometimes  seen  in  feeble  women,  especially  those  who  have  been  in 
wretched  health  before  puberty.  The  nymphae  may  be  absent,  very  small,  or 
hypertrophied. 

(5)  Clitoris. — Defects  in  the  clitoris  are  often  of  great  clinical  significance. 
Its  absence  is  a  rare  condition,  but  it  is  not  so  infrequently  hypertrophied,  in 
some  cases  to  such  an  extent  that  it  is  difficult  or  impossible  to  differentiate  the 
■sex  of  the  individual.  It  is  sometimes  rudimentary  or  even  bifid,  as  when  the 
symphysis  is  absent,  or  in  exstrophy  of  the  bladder  (see  Deformities  and  Mon- 
strosities, page  247). 

(6)  Hymen. — The  hymen  may  also  present  deformities.  It  may  be  imper- 
forate, or  there  may  be  atresia.  The  supernumerary  hymen  that  has  been  re- 
ported is  probably,  as  a  rule,  a  vaginal  bridle.  The  congenital  absence  of  this 
membrane  is  open  to  grave  doubt,  although  instances  of  the  anomaly  have  been 
reported  from  time  to  time.  In  600  cases  of  children  under  sixteen  years,  exam- 
ined by  the  writer  for  evidences  of  rape,  in  no  instance  was  the  hymen  absent 
(see  Rape,  page  29). 

Malformations  of  the  urethra  and  bladder  are  various.  The  urethra  may  be 
■entirely  absent,  or  only  partly  defective.  Atresia  urethra  sometimes  exists,  but 
generally  ends  fatally. 

Clinical  Significance  of  Deformities. — Malformation  of  the  uterus  rnay 
affect  the  course  of  pregnancy  and  labor  in  various  ways.  In  uterus  septus  duplex 
there  are  a  few  cases  in  which  the  placenta  has  been  located  upon  a  persisting 
septum,  post-partum  hemorrhage  occurring  from  deficient  retraction.  The  empty 
half  of  the  uterus  may  of  itself  become  an  obstruction  to  labor,  especially  if  it 
be  hypertrophied  and  retroverted.  During  labor  it  is  very  apt  to  sink  into  the 
sacral  hollow,  and  contract  synchronously  with  the  musculature  of  the  pregnant 
part.  The  pregnant  side  of  the  uterus  turns  toward  the  median  line  of  the  body. 
The  clinical  significance  of  this  malformed  organ  is  similar  to  that  of  the  uterus 
duplex  bicornis.  In  uterus  arcuatus  brow  and  face  presentations  are  favored 
when  the  breech  is  in  that  segment  of  the  fundus  which  corresponds  to  the  back 
of  the  fetus.  When  pregnancy  occurs  in  the  anvil-shaped  uterus  (uterus  in- 
€udiformis)  the  fetus  is  forced  to  assume  the  transverse  position,  on  account  of 
the  shape  of  the  uterus,  which  is  flattened,  having  the  transverse  at  its  greatest 
■diameter.  In  the  cordate  uterus,  the  cavity  being  only  slightly  smaller  than 
normal,  a  two-chambered  organ  is  merely  suggested.  When  the  utero-vaginal 
septum  is  complete,  sexual  intercourse  may  take  place  in  either  canal.  In  labor 
the  septum  itself  may  offer  an  obstruction.     Laceration  of  the  septum  often 


288  PATHOLOGICAL  PREGNANCY. 

takes  place.  In  uterus  duplex  bicornis  with  pregnancy  in  one  horn,  the  uterine 
obliquity  necessarily  present  may  be  a  cause  of  faulty  presentation,  position,  and 
attitude.  When  pregnancy  occurs  in  one  horn,  confusion  in  the  diagnosis  with 
the  condition  of  tubal  pregnancy  can  scarcely  be  avoided.  Menstruation  may 
take  place  from  one  horn,  while  pregnancy  exists  in  the  other.  Different  periods 
of  pregnancy  may  exist  simultaneously  in  the  two  horns ;  labor  is  sometimes 
obstructed  by  the  vesico-rectal  ligament  which  connects  the  two  horns  in  a 
bicornate  uterus.  Associated  with  this  malformation  are  apt  to  be  atony,  weak 
labor  pains,  and  faulty  involution.  In  the  uterus  unicornis  with  pregnancy  in 
that  part  of  the  uterus  which  has  become  developed,  labor  is  usually  normal. 
If,  however,  pregnancy  occurs  in  the  rudimentary  horn,  the  course  and  termina- 
tion of  the  case  will  be  similar  to  that  of  extrauterine  pregnancy  (see  page  361). 
The  rudimentary  horn  is  not  suited  for  the  normal  course  of  gestation,  and  if  this 
occurs  it  results  in  rupture  before  the  sixth  month.  The  danger  of  this  condition 
is  as  great  as  that  of  tubal  pregnancy,  from  which  it  cannot  be  differentiated 
before  operation.  In  the  event  of  atresia  of  the  stunted  horn,  hematometra  will 
develop,  the  diagnosis  of  which  it  may  be  impossible  to  determine  without  opera- 
tion. This  may  develop  into  pyometra.  When  the  true  nature  of  this  condi- 
tion is  known,  it  is  important  to  open  this  retention  cyst  and  allow  the  contents 
to  flow  slowly  out,  in  order  to  avoid  a  sudden  change  of  pressure,  which  might 
result  in  the  bursting  of  this  thin-walled  sac  into  the  abdominal  cavity.  This 
would  put  the  patient  in  great  danger  of  infection  and  septicemia.  Especially 
is  this  caution  necessary  when  hematosalpinx  exists  as  a  complication.  Should 
the  tumor  rupture  of  itself,  the  tear  may  be  so  high  up  that  a  part  of  the  sac  will 
be  left  too  far  out  of  reach  to  be  properly  drained,  and  this  condition  will  also  be 
followed  by  infection  and  septicemia.  In  uterus  hiforis  (one-homed  uterus  with 
double  cervix)  there  may  be  considerable  trouble  during  labor.  If  the  septum  is 
found,  it  may  be  pushed  to  one  side  and  so  kept  out  of  the  way,  or  it  may  be  cut 
between  two  lines  of  sutures.  Severe  hemorrhage  has  followed  its  rupture.  It 
is  plain  to  see  how  any  of  the  foregoing  deformities  may  cause  trouble  of  various 
sorts  and  degrees.  There  may  be  trouble  with  the  placenta,  as  it  is  not  infre- 
quently retained.  This  may  be  due  to  the  weak  force  of  expulsion,  or  to  its 
attachment  to  both  cavities  of  the  uterus.  This  retention  may  be  the  cause  of 
septicemia.  When  labor  is  proceeding,^  the  physician  may  examine  the  two  open- 
ings alternately,  finding  now  a  dilated  os,  then  a  contracted  os.  Or  the  wrong 
side  may  be  examined,  and  no  internal  signs  of  pregnancy  be  found.  In  the  case 
of  one  individual  with  a  double  uterus,  succeeding  pregnancies  occurred  regu- 
larly on  the  alternate  sides. 

13.  Leucorrhea. — One  often  observes  excessive  leucorrhea  as  the  result  of 
the  congestion  of  pregnancy,  and  following  or  accompanying  acute  or  chronic 
inflammation,  non-specific  in  character.  Much  annoyance  is  caused  by  the  dis- 
charge itself,  and  the  swelling,  heat,  and  general  discomfort.  The  profuse  serous 
discharge  becomes  later  purulent  and  contains  various  fungi.  In  the  treatment 
care  should  be  exercised  not  to  excite  uterine  contractions.  The  author  is 
accustomed  to  rely  mainly  upon  suppositories  of  hydrochlorate  of  hydrastis, 
gr.  i;  borate  of  zinc,  gr.  \;  extract  of  belladonna,  gr.  \;  cocoa-butter,  or  boro- 
glyceride  and  cocoa-butter,  q.s.  After  careful  irrigation  of  the  vagina  at  bedtime 
with  an  alum  douche,  a  teaspoonful  of  alum  to  the  quart  of  warm  water,  care  being 
taken  that  there  is  no  obstruction  to  the  return  flow,  and  that  the  douche  bag  is 
not  more  than  two  feet  above  the  pelvis,  one  of  the  above  suppositories  is  inserted 
into  the  vagina,  and  a  napkin  applied  for  the  night.  In  the  morning  the  alum 
douche  is  repeated.     Other  combinations  in  suppositories  are  useful.     When  the 


DISEASES   OF   THE  GENITAL  ORGANS.  289 

uterus  is  irritable,  or  the  vagina  painful  or  sensitive,  suppositories  of  extract 
of  belladonna  gr.  -J,  and  tannic  acid  gr.  5-10,  are  used;  and  the  douche  is  omitted 
entirely;  or  a  solution  of  subacetate  of  lead  two  teaspoonfuls,  and  laudanum  two 
teaspoonfuls,  to  the  quart  of  warm  water,  is  used.  Care  must  be  taken  during 
pregnancy  in  the  employment  of  any  form  of  tampon  with  the  various  prepara- 
tions of  boro-glyceride,  tannin,  zinc,  and  hydrastis. 

14.  Cystic  Vaginitis. — This  is  an  inflammation  of  the  vagina,  usually  limited 
to  the  upper  two-thirds,  and  accompanied  by  the  development  of  small  cysts, 
from  which,  when  punctured,  air  and  serum  exude;  it  is  attended  by  a  profuse 
frothy  discharge,  and  the  symptoms  are  more  acute  than  those  of  simple  catar- 
rhal vaginitis.     The  treatment  is  the  same  as  for  leucorrhea. 

15.  Specific  Vaginitis. — The  infection  takes  place  as  the  result  of  sexual 
intercourse,  but  in  rare  cases  it  may  possibly  be  caused  by  the  use  of  infected 
towels,  or  by  other' contact  with  infected  surfaces.  All  the  symptoms  of  simple 
vaginitis  are  aggravated ;  there  are  urethritis  and  vesical  irritation ;  the  discharge 
is  profuse  and  purulent,  and  contains  the  gonococcus  (diplococcus  of  Neisser); 
smarting  pain  accompanying  urination  is  especially  prominent ;  abscesses  of  the 
vulvo-vaginal  gland  sometimes  occur,  and  redness  and  excoriation  of  the  external 
genitals  are  common.  There  is  always  considerable  danger  of  septic  infection 
during  labor,  and  the  fetus  is  likely  to  develop  specific  ophthalmia.  Treatment: 
The  vagina  should  be  irrigated  with  an  antiseptic  solution,  sublimate  solution 
(i :  4000),  or  permanganate  of  potash,  and  excoriated  surfaces  cauterized  with  a 
2  per  cent,  solution  of  nitrate  of  silver;  loose  tampons  of  boro-glyceride  and 
tannin,  or  of  iodoform  and  tannic  acid,  may  be  used;  suppositories  of  iodoform, 
tannic  acid,  and  cocoa-butter,  or  hydrastin  and  boro-glyceride  used  at  bedtime. 
The  introduction  of  the  suppository  should  be  preceded  and  followed  by  a  warm, 
carefully  administered  lysol  or  creolin  douche  (i  per  cent.).  Since  the  vaginal 
secretions  are  alkaline  in  this  affection,  Doderlein  has  suggested  the  topical  appli- 
cation of  a  I  per  cent,  solution  of  lactic  acid  to  the  vaginal  walls.  Antiseptic 
vaginal  douches  during  labor  are  advisable,  and  after  delivery  the  child's  eyes 
should  be  washed  with  a  saturated  solution  of  boric  acid,  and  nitrate  of  silver  be 
instilled  into  each  eye,  after  the  method  of  Cred^  (see  Part  IX). 

16.  Prolapse  of  the  Vagina. — In  multigravidas,  and  occasionally  in  primi- 
gravidae, — in  the  former  from  a  previously  existing  condition,  and  in  both  as 
the  result  of  the  changes  produced  by  gestation,  such  as  congestion,  increased 
pressure,  hypertrophy  and  loosening  of  the  vaginal  walls, — a  certain  amount 
of  prolapse  of  the  anterior  wall,  associated  with  perhaps  some  cystocele,  is  com- 
mon in  the  later  months  of  pregnancy.  Prolapse  of  the  posterior  wall  with 
cystocele  we  not  infrequently  see  in  multigravidae,  and  occasionally  in  primi- 
gravidcB,  from  habitual  constipation  with  overloaded  rectum  and  neglect.  I  once 
saw  a  prolapse  of  the  posterior  wall  with  rectocele,  in  a  primigravida,  due  to 
persistent  constipation,  in  which  the  rectocele  presented  in  the  ostium  vaginse; 
I  was  summoned  in  the  night,  the  patient  mistaking  the  condition  for  a  possible 
miscarriage.  The  symptoms  are  those  of  vesical  and  rectal  irritation,  dysuria, 
frequent  micturition,  and  perhaps  aggravation  of  existing  hemorrhoids;  the 
physical  signs  are  plain  on  examination.  The  treatment  consists  in  careful  atten- 
tion to  the  bowels,  the  avoidance  of  tight  clothing,  the  manual  reposition  of  the 
prolapse,  and  in  fitting  a  proper  abdominal  support  to  the  patient,  to  lessen  the 
weight  of  the  uterus  (Figs.  228  and  229).  The  abdominal  binder  described  for 
use  after  the  puerperium  can  be  employed  to  advantage,  since  it  supports  the 
lower  part  of  the  uterus  and  the  pelvic  floor  as  well  (see  Part  VI).  A  pneumatic, 
water,  or  celluloid  pessary  may  possibly  be  required,  held  in  place  by  the  above, 

19 


290 


PATHOLOGICAL  PREGNANCY. 


Fig.  466. — Varicose  Veins    of   the  Vulva. 
— {Case  of  Dr.  Wihner  Krusen) 


or  an  ordinary  T-bandage.     During  labor  prolapse  may  prove  an  obstruction 
(see  Part  V). 

17.  Pruritus  Vulvae. — This  is  always  a  source  of  great  annoyance,  and  occa- 
sionally of  miscarriage.  It  is  due  to  irritating  discharges  or  to  local  conditions; 
it  often  occurs  in  diabetes.  It  may  have  a  reflex  origin,  as  rectal  worms, 
and    some    have    asserted   that  it  is  frequently  a  neurosis.      Treatment:    The 

general  health  should  be  attended 
to  and  the  cause  should  be  ascer 
tained,  and  treated  if  possible;  the 
urine  being  always  carefully  ex- 
amined for  sources  of  irritation, 
as  sugar  and  uric  acid.  I  have 
found,  after  correcting  the  irri- 
tating discharges  and  attending  to 
the  urine  and  bowels,  that  sublimate 
solution  (i:  1000)  is  of  great  value 
in  subduing  the  itching;  carbolic 
acid,  either  in  ointment  or  solution, 
is  of  value;  a  drachm  of  carbolic 
acid  to  four  ounces  of  ointment  of 
rose,  or  to  eight  ounces  of  water 
or  oil,  may  be  used.  Ointments  of 
cocain,  ichthyol,  resorcin,  menthol, 
opium  and  belladonna,  and  salicylic 
acid  are  recommended. 

18.  Varicosities  (Fig.  466). — Va- 
ricose veins  about  the  vulva  and  lower  part  of  the  vagina,  the  result  of  the 
general  pelvic  congestion,  frequently  occur.  Constipation  should  be  avoided, 
and  in  bad  cases  the  vulval  region  should  be  supported  by  a  T-bandage,  and 
the  patient  should  spend  a  good  deal  of  time  in  the  recumbent  position.  The 
compound  ointment  of  gall,  and  ointments  of  carbolic  acid, '  cocain,  and 
witch-hazel  I  have  found  useful. 
\  ■  19.  Vegetations. — These  often 
follow  gonorrhea,  especially  when 
the  rules  of  cleanliness  are  not 
observed;  they  are  confined  to  the 
vulva.  Cleanliness  and  the  fre- 
quent application  of  an  astringent 
powder,  as  oxide  of  zinc,  or  bis- 
muth and  salicylic  acid,  boro- 
glyceride  and  tannin,  will  be  suffi- 
cient for  treatment;  bad  cases  may  *  '  '  ,,^«j,.'/ 
be  touched  with  chromic  acid,  but 
operative  treatment  should  be 
avoided  during  pregnancy. 

20.  (Edema  of  the  Vulva  (Fig. 
467). — (Edema  here  may  be  uni- 
lateral or  bilateral;  it  may  be  due  to  renal  insufficiency,  in  which  case  it  is  always 
bilateral,  or  to  mechanical  pressure  of  the  enlarging  uterus  and  fetus  upon  the 
pelvic  veins.  It  may  also  be  due  to  general  anasarca,  or  to  local  inflamma- 
tion, as  specific  vaginitis.  When  excessive,  ulcerative  sloughing  of  the  labia 
may  occur,  and  labor  be  obstructed  (see  Part  V).     In  the  treatment  the  cause 


Fig.  467. — CEdema  of  the  Vulva. 


TOXEMIA   OF  PREGNANCY.  291 

is  to  be  sought  out  and  treated :  diuretics  for  the  renal  insufficiency ;  an  abdomi- 
nal support  for  pressure;  proper  treatment  for  local  inflammation.  Hot  fomen- 
tations and  multiple  puncture  of  the  tense  skin  are  palliative;  the  latter  should 
be  avoided  when  possible,  for  fear  of  local  infection. 

21.  Eczema  of  the  Nipple. — This,  when  occurring  during  gestation,  is  apt  to 
be  a  very  obstinate  affection.  For  treatment  the  general  health  should  receive 
attention.  Locally  the  parts  affected  should  be  kept  clean,  frequent  washing 
being  avoided;  antiseptic,  astringent,  and  desiccating  applications  should  be  used; 
powdered  oxide  of  zinc  and  salicylic  acid  make  a  good  application.  The  nipples 
are  to  be  guarded  from  irritation  and  exposure  to  the  air  by  a  protective  dress- 
ing, which,  however,  should  not  press  upon  them.  The  condition  is  apt  to  resist 
treatment.  I  have  been  most  successful  with  the  use  of  Unna's  ointment  mull, 
hydrarg.  carbolic,  (hydrarg.,  20  per  cent.;  carbolic  acid,  5  per  cent.),  cutting  a 
piece  of  the  plaster  to  fit  accurately  over  the  affected  part,  and  renewing  it  daily, 
using  only  a  little  sterile  vaseline  in  the  removal  of  the  plaster. 

22.  Mammary  Abscess. — This  may  occur  during  pregnancy,  but  is  not 
common.  I  had  in  my  service  at  the  New  York  Maternity  a  case  of  double 
mammary  abscess  at  the  eighth  month  of  gestation,  which  was  twelve  months 
from  the  birth  of  the  last  child.  Both  breasts  were  incised,  and  drainage  was 
employed  without  interrupting  the  pregnancy.  It  frequently  occurs  during 
the  puerperium,' and  is  discussed  in  connection  with  the  pathology  of  that 
period  (see  Part  VII). 

23.  Hemorrhage  from  the  Vagina  During  Pregnancy. — (See  Metrorrhagia  of 
Pregnancy.) 

24.  Hematoma  of  the  Vulva. — The  veins  of  the  vestibular  bulbs,  lying  be- 
neath the  mucous  membrane  of  the  vestibule  on  either  side,  are  liable  to  rupture 
during  pregnancy,  giving  rise  to  hematoma  of  the  vulva,  and  possibly  profuse 
external  hemorrhage.  The  condition  is  found  more  frequently  during  parturi- 
tion and  the  puerperium.     (See  Pathology  of  Labor  and  Puerperium.) 


X.  THE  TOXEMIA    OF   PREGNANCY.     AUTOTOXEMIA   OF 
PREGNANCY.     HEPATIC  INSUFFICIENCY.     PREG- 
NANCY LIVER.     PRE-ECLAMPTIC  STATE. 

I.   Toxerma  of  Pregnancy.     2.  Nausea  and  Vomiting.     3.  Icterus      4.  Convulsions  and  Coma. 

5.  Eclampsia. 

I.  Toxemia  of  Pregnancy. — Introduction. — The  conception  of  a  special 
toxemia  of  pregnancy  has  grown  from  small  and  vague  beginnings  to  a  well- 
developed  and  harmonious  theory  which  challenges  the  attention  of  every 
medical  man.  That  such  a  condition  exists  is  no  longer  a  matter  of  doubt; 
but  the  extent  to  which  it  prevails  will  unquestionably  be  a  subject  of  debate 
in  obstetrics  for  many  years  to  come. 

It  is  unnecessary  to  refer  in  detail  to  the  various  discoveries  which  have  cul- 
minated in  the  modern  theory  of  the  toxemia  of  pregnancy,  which  is  sufficiently 
well  established  to  admit  of  a  statement  of  the  etiology,  pathology,  symptoma- 
tology, clinical  varieties,  course  and  termination, diagnosis,  prognosis,  prophylaxis, 
and  treatment.  As  far  as  is  known,  the  subject  in  question  has  thus  far  never 
been  dealt  with  in  this  systematic  fashion,  and  I  am  under  obligation  to  Ewing  for 
filling  out  certain  gaps  in  my  attempts  in  this  direction. 


292  PATHOLOGICAL  PREGNANCY. 

Definition. — The  toxemia  of  pregnancy  may  be  defined  as  a  state  of  the 
blood  and  metabohsm,  possibly  arising  from  the  hepatic  insufficiency,  to  which 
the  pregnant  woman  is  strongly  predisposed ;  expressed  most  commonly  by  trivial 
ailments  (petty  morbidity  of  pregnancy),  but  exceptionally  by  serious,  severe, 
and  even  pernicious  affections,  such  as  acute  yellow  atrophy  of  the  liver,  per- 
nicious vomiting,  eclampsia, — conditions  which,  while  once  thought  to  have- 
nothing  in  common,  are  now  seen  to  be  closely  related. 

Pathological  Anatomy. — The  anatomical  alterations  chiefly  affect  the 
liver,  kidneys,  and  spleen.  Exceptionally  other  organs  may  be  involved,  as 
peripheral  nerves,  thyroid,  etc.  The  blood  state  in  fatal  cases  resembles  that 
of  severe  sepsis.  Liver:  Lesions  of  this  organ  are  constantly  present,  but  exhibit 
great  irregularity  in  extent  and  severity.  They  are  either  degenerative  or 
necrotic,  the  latter  succeeding  the  former.  We  may  encoiinter  extensive  areas 
of  degeneration  without  necrosis,  and,  conversely,  may  see  necrosis  result  from 
isolated  foci  of  degeneration,  A  certain  degree  of  fatty  metamorphosis  (stea- 
tosis) is  said  to  be  the  rule  in  pregnancy;  and  from  these  minimal  changes  there 
may  occur  a  steady  increase  in  intensity  until  acute  parenchymatous  hepatitis 
is  reached,  this  condition  consisting  of  an  acute  fatty  degeneration,  plus  a 
proliferation  of  the  interlobular  connective  tissue  (Fig.  468).  In  like  manner 
necrosis  may  develop  in  foci  of  fatty  degeneration,  and  may  occur  in  in- 
creasing severity  until  it  culminates  in  acute  yellow  atrophy  of  the  liver  (Fig. 
469).  Whenever  necrosis  reaches  a  certain  stage  the  blood-vessels  become  in- 
volved, and  hemorrhages  and  thrombosis  may  result  ( Fig.  469).  The  most  severe 
lesions  of  the  liver  are  partly  degenerative  and  partly  necrotic;  for  this  reason 
the  size  and  appearance  of  the  liver  in  the  acute  toxemia  of  pregnancy  may  vary 
greatly.  In  one  instance  the  organ  may  be  the  seat  of  acute  parenchymatous 
hepatitis  with  no  diminution  in  size,  while  in  another,  the  necrotic  element  is 
so  marked  that  the  size  may  be  reduced  to  a  third  of  the  normal.  Even  in  the 
midst  of  the  extensive  destruction,  there  is  evidence  of  attempted  regeneration 
of  biliary  canaliculi.  Ewing,  regarding  necrosis  of  the  hepatic  cell  as  almost 
inseparable  from  the  acute  toxemia  of  pregnancy,  gives  the  following  degrees  of 
intensity :  Necrosis  may  be  limited  to  individual  isolated  cells  throughout  a  lobule ; 
or  it  may  involve  the  zone  of  cells  between  the  central  vein  and  the  periphery;  or, 
finally,  it  may  involve  the  entire  lobule,  save  a  slight  peripheric  rim  of  cells 
(Figs.  468,  469).  Kidney:  The  appearances  of  the  kidney  are  very  irregular. 
Not  only  does  the  specific  pregnancy-kidney  occur  under  a  variety  of  forms,  but 
it  may  be  complicated  with  nephritis,  which  affection  may  also  occur  de  novo. 
Although  some  pathologists  deny  the  existence  of  a  specific  kidney  of  pregnancy, 
the  characteristics  laid  down  by  von  Leyden  appear  to  demonstrate  the  existence 
of  a  condition  sui  generis.  From  this  point  of  view  the  pregnancy-kidney  is  an 
acute  fatty  infiltration  of  the  kidney  which  does  not  compromise  the  integrity 
of  the  organ,  and  which  tends  to  disappear  after  delivery.  In  rare  instances 
acute  toxemia  of  pregnancy  is  found  to  be  associated  with  an  acute  parenchy- 
matous nephritis,  terminating  in  atrophy.  The  connection  of  such  a  lesion 
with  the  specific  kidney  of  pregnancy  is  a  matter  of  speculation.  Spleen:  In 
acute  toxemia  of  pregnancy,  associated  with  hepatitis  and  necrosis  of  the  liver, 
the  spleen  may  be  similarly  involved.  The  damage  thus  inflicted  upon  this  organ 
is  held  by  some  to  account  for  the  mysterious  examples  of  anemia  and  leukemia 
which  develop  after  the  puerperium.  Nerves:  Polyneuritis  occurs  in  the  gravida 
to  a  greater  extent  than  may  be  explained  by  chance.  In  some  cases  the  phrenic 
nerve  has  been  involved.  Korsakoff's  psychosis  (mania  with  polyneuritis)  has 
also  been  seen  in  the  gravida.     Thyroid:  The  normal  enlargement  of  this  organ 


?       ^ 


t 


»  • 


Normal    liver 
cells. 


Zone  of  intense 
granular  and 
fatty  degener- 
ation. 


Zone  of  necro- 
sis about  cen- 
tral vein. 


Fig.  468. — Toxemia  of  Pregnancy.  Portion  of  an  hepatic  lobule  from  a  case  of  the  toxemia 
of  pregnancy.  Specimen  shows  intense  granular  and  fatty  degeneration,  and  also  zone  of 
necrosis  about  the  central  vein,  x  75  diameters. — (From  a  specimen  in  the  Pathological 
Laboratory  of  the  Cornell  Uni"c'crsity  Medical  College.) 


TOXEMIA   OF  PREGNANCY.  293 

in  the  gravida  has  been  found  wanting  in  certain  cases  of  eclampsia.  Blood: 
In  high  degrees  of  toxemia  of  pregnancy  the  blood  shows  characteristic  changes 
which  resemble  those  of  sepsis.  Thrombosis  and  embolism  may  occur,  begin- 
ning in  the  hepatic  veins.  Another  feature  of  this  state  is  the  acute  hemor- 
rhagic diathesis,  which  leads  to  surface  hemorrhages  (petechiae  or  extravasa- 
tions). Finally  icterus  may  be  enumerated  among  the  symptoms  of  the  acute 
dyscrasia  of  the  blood. 

Etiology. — There  are  three  sets  of  etiological  factors  which  must  be  con- 
sidered in  connection  with  the  toxemia  of  pregnancy:  i.  Conditions  which 
predispose  to  hepatic  insufficiency,  comprising  pregnancy  itself,  heredity  and 
a  previous  history  of  toxemia.  2.  Accessory  factors  which  tend  to  modify  the 
disease  and  cause  it  to  assume  special  clinical  types,  and  to  influence  the  time 
of  its  appearance;  these  comprising  nervous  instability,  the  menstrual  epoch, 
and  mechanical  factors.  3.  Actual  toxic  substances  in  the  blood,  or  toxic 
states  of  that  fluid.  The  exact  relation  of  this  class  of  factors  to  the  hepatic 
insufficiency  is  problematical,  because  a  vicious  circle  is  involved.  Thus  a 
toxic  blood-state  may  by  throwing  additional  work  upon  the  liver  cause  a 
partial  paralysis  of  its  functions,  which  in  turn  causes  the  accumulation  of  more 
toxic  matter  in  the  blood.  Each  individual  factor  will  now  receive  separate 
discussion. 

1 .  Pregnancy. — This  is  the  sine  qua  non  among  etiological  factors ;  for  while 
many  of  the  phenomena  of  the  toxemia  of  pregnancy  may  occur  in  the  non- 
pregnant, some  of  the  lesions  of  the  liver  and  kidney  appear  to  occur  only  in 
gravidity,  while  clinically  the  course  of  the  malady  is  intimately  bound  up  with 
gestation.  The  frequent — yet  by  no  means  universal — cessation  or  great 
amelioration  of  the  symptoms  after  death  of  the  fetus  or  emptying  of  the  uterus 
is  alone  sufficient  evidence  of  the  specificity  of  this  affection.  The  relationship 
of  pregnancy  to  the  autotoxic  state  is  considered  more  fully  under  pathogeny. 
Hereditary,  Congenital  and  Acquired  Tendency  to  Hepatic  Insufficiency:  For  the 
great  influence  of  heredity  in  this  connection  see  page  2 98.  We  may  also  infer  that 
hepatic  insufficiency  may  be  acquired  in  various  ways.  Previous  History  of  Toxe- 
mia of  Pregnancy:  In  a  large  proportion  of  cases  one  attack  appears  to  predispose 
to  another  at  a  consecutive  pregnancy.  This  is  especially  likely  to  happen  if  the 
first  attack  was  of  sufficient  severity  to  produce  structural  alterations  of  the  vis- 
cera. Even  in  the  absence  of  a  history  of  toxemia,  the  mere  fact  that  children  of  a 
given  woman  are  bom  in  rapid  succession  may  furnish  a  very  strong  predisposi- 
tion ;  for  the  toxemia,  however  slight  or  latent,  may  become  cumulative.  If  the 
toxemic  symptoms  are  not  resolved  after  delivery  and  persist  into  the  lacta- 
tion period,  conception  would  likely  be  followed  by  toxemia  in  an  aggravated 
form.  In  this  connection  we  may  cite  the  statement  by  Ewing  that  in  some 
cases  of  dysmenorrhea  antedating  conception  the  women  exhibit  evidences 
of  a  toxic  condition  resulting  apparently  from  suppression  of  the  menses. 
A  woman  of  this  sort  is  notably  predisposed  to  toxemia  in  case  of  con- 
ception. 

2.  Accessory  Factors. — Numerous  factors  help  to  shape  the  course  of  the 
toxemia.  The  nervous  instability  which,  according  to  von  Herff,  is  almost 
inseparable  from  pregnancy,  and  which  perhaps  is  itself  evidence  of  an  autotoxic 
state,  undoubtedly  plays  a  very  prominent  role — in  proportion  to  its  degree — 
in  the  causation  of  paroxysms  of  vomiting  and  eclamptic  convulsions.  If  reflex 
irritation  is  the  factor  in  the  morbidity  of  pregnancy  which  many  assume,  it 
can  be  such  only  through  the  accession  of  nervous  instability.  An  important 
factor  for  determining  the  onset  and  exacerbation  of  symptoms  is  the  time  of 


294  PATHOLOGICAL  PREGNANCY. 

the  menses.  Thus  hyperemesis  may  first  set  in  or  become  much  aggravated  or 
develop  terminal  symptoms,  at  the  end  of  the  various  months  of  pregnancy. 
When  the  increase  of  the  ovum  and  uterus  is  of  such  extent  as  to  raise  the  intra- 
abdominal pressure,  compress  important  organs,  and  interfere  with  circulation 
and  respiration,  this  mechanical  factor  often  becomes  of  great  significance  in  the 
development  of  pregnancy-kidney,  and  other  conditions — constipation,  for 
example — which  may  increase  the  severity  of  the  autotoxic  state. 

3.  Toxic  Substances  and  Influences. — (i)  Nitrogenous  substances  derived 
either  from  katabolic  activity  or  from  the  ingesta  are  most  commonly  suspected 
of  participating  in  the  toxemia  of  pregnancy.  The  failure  of  the  liver  to  syn- 
thetize  the  lower  nitrogenous  products  of  katabolism  to  urea  and  uric  acid  is 
held  to  be  responsible  for  the  accumulation  of  these  substances  in  the  blood. 
There  are  included  here  amino-acids,  ammonia,  xanthin  bases,  etc.  However, 
but  one  of  these — carbaminic  acid — is  a  known  chemical  poison;  and  this  has 
not  yet  been  found  in  the  blood  in  toxic  quantities.  If  the  toxic  state  already 
exists,  a  nitrogenous  diet  appears  to  favor  greatly  the  development  of  convul- 
sions; this  fact  arguing  that  the  peptones  and  peptoids  of  digestion  normally 
require  disintoxication  by  the  liver  before  they  are  fit  for  assimilation.  Finally, 
nitrogenous  products  of  putrefaction,  ordinarily  rendered  harmless  by  the  liver, 
may  be  pathogenic  in  the  gravida.  (2)  Bile:  From  the  frequent  use  of 
the  term  cholemia  as  a  synonym  for  toxemia  of  pregnancy,  it  might  be 
thought  that  the  condition  represents  an  absorption  or  suppression  of  the 
bile.  This  is  not  the  case,  however.  Bile  when  injected  into  animals 
possesses  narcotic  properties,  but  there  is  not  much  evidence  that  bile  per  se 
or  the  substances  from  which  it  is  produced  plays  any  important  role  in  the 
genesis  of  the  autotoxic  state  of  the  gravida.  At  the  same  time  it  is  by  no 
means  impossible  that  such  is  the  case.  The  subject  is  considered  more  fully 
under  pathogeny.  (3)  Changes  in  the  normal  alkalescence  or  concentration  of 
the  blood  may  be  responsible  for  the  toxic  phenomena.  Thus  the  same  dimi- 
nution of  the  alkalescence  which  is  known  to  exist  in  diabetic  coma  (so-called 
acid-intoxication)  may  be  noted  in  the  acute  toxemia  of  pregnancy.  This  is 
held  to  be  due  to  the  presence  of  "acetone  bodies  "  (acetone,  aceto-acetic  acid), 
of  lactic  acid  and  the  higher  fatty  acids,  and  probably  represents  imperfect 
oxidation  of  carbohydrates.  In  this  condition  the  urine  gives  an  intense  acid 
reaction.  The  opposite  state  of  increased  alkalescence  is  seen  under  experi- 
mental conditions  (Eck's  fistula)  and  perhaps  clinically  as  well — as  in  cases  in 
which  the  breath,  urine,  etc.,  are  ammoniacal.  (4)  Occasional  or  Chance  Poisons: 
Since  the  liver  of  the  gravida  is  in  a  state  of  exhaustion,  it  is  well  to  bear  in  mind 
that  it  may  not  be  able  to  fix  and  neutralize  ordinary  poisons  of  alien  source  which 
have  a  special  tendency  to  injure  it.  These  comprise  phosphorus,  arsenic  and 
antimony,  alcohol  when  taken  habitually,  and  perhaps  other  substances  of  a 
similar  nature.     Bacterial  toxins  must  also  be  borne  in  mind  as  chance  factors. 

Pathogeny. — Pregnancy  itself  is  doubtless  the  efficient  cause  of  the  hepatic 
overwork,  for  the  liver  presides  over  anabolism  and  must  be  largely  concerned 
in  the  upbuilding  of  the  fetus.  The  importance  of  the  hepatic  tissue  to  the 
growing  organism  is  best  seen  in  the  disproportionally  large  size  of  the  liver  in 
the  fetus  and  infant.  It  is  often  stated  that  the  maternal  liver  should  not  be 
overtaxed  in  the  early  months  of  pregnancy;  and  this  may  be  true  in  the  sense 
that  the  products  of  embryonal  katabolism  must  be  insignificant;  we  must 
bear  in  mind,  however,  that  during  the  embryonal  period  a  rapid  organogenesis 
occurs;  and  that  the  various  tissues  and  organs  are  all  rapidly  evolved  from  a 
relatively  undifferentiated  matrix.     It  is  commonly  affirmed  that  this  rapid 


&"^i)^^ 


/ 


'&'k^^  ^y ; 


Per  i  p  Ii  era  I 
row  of  in- 
tact cells. 


Narrozv  zone 
of  very  fat- 
tv  cells. 


Edge  of  area 
of  necrotic 
and  disin- 
tegrated 
cclls.zi'Iiicli 
occupy  in- 
}i  c  r  t  tv  0- 
th  irds  of 
lobu'e. 


Fig.  469.— Toxemia  of  Pregnancy.  Portion  of  an  hepatic  lobnlo  from  a  case  of  pornicimis 
vomiting  of  pregnancy.  Specimen  siiows  fatty  degeneration  and  necmsis.— (/■';•<»//;  a 
spccniini  iu  flic  Pathological  Laboratorv  of  ihc  Cornell  University  Medical  Collate.) 


TOXEMIA   OF  PREGNANCY.  295 

differentiation  is  accomplished  by  the  aid  of  enzyme-like  bodies,  which  are 
generated,  do  their  work,  and  g-ive  way  to  others.  While  it  is  often  said  that 
the  maternal  blood  contains  all  these  potentialities  for  fetal  development, 
it  would  be  more  nearly  correct  to  state  that  this  responsibility  is  invested  in 
the  chief  hematopoietic  organ — the  liver. 

To  this  drain  upon  the  liver  must  be  added  the  influence  of  suppressed  men- 
struation in  the  gravida,  which  is  said  to  entail  congestion  of  the  liver,  and  per- 
haps also  retention  of  toxic  substances  in  the  circulation.  If,  now,  the  various 
predisposing  causes  are  borne  in  mind,  as  heredity,  previous  toxemia  of  preg- 
nancy, etc.,  we  may  readily  conceive  of  causal  factors  which  may  explain  the 
"failure  of  the  liver  "  even  when  it  occurs,  as  in  rare  cases,  early  in  pregnancy. 

As  pregnancy  advances  the  risk  increases.  Thus  the  gravida  after  subsidence 
of  preliminary  nausea,  etc.,  may  develop  a  voracious  appetite,  and  may  take 
large  quantities  of  nitrogenous  food.  The  steady  growth  of  the  uterus  and 
ovum  must  add  in  time  to  the  katabolic  work  of  the  liver.  The  increase  of  intra- 
abdominal pressure  must  be  prejudicial  to  the  work  of  that  organ;  and  the 
obstinate  locking-up  of  the  bowels  which  frequently  occurs  must  favor  the 
absorption  of  putrefactive  products.  The  woman  cannot  exercise,  and  her 
respiratory  activity  is  prejudiced.  To  all  these  contingencies  must  be  added 
the  possibility  of  some  bacterial  infection,  an  addiction  to  alcohol,  or  some  form 
of  drug-poisoning,  as  from  arsenical  wall-paper,  "complexion  wafers,"  etc. 

Toxemia  in  pregnancy  has  been  noted  in  connection  with  ectopic  gestation 
and  even  with  hydatidiform  mole.  The  latter  fact  appears  to  disprove  the 
likelihood  of  a  fetal  source  of  toxemia. 

Symptomatology. — Some  of  the  more  important  and  constant  symptoms 
require  special  attention.  These  may  be  grouped  under  the  following  heads: 
viz.,  gastro-hepatic,  urinary,  nervous,  and  cutaneous.  G astro-hepatic:  While  by 
no  means  constant,  pain  and  tenderness  over  the  epigastrium  and  right  hypo- 
chondrium  are  not  infrequent.  The  area  of  hepatic  dulness  may  be  increased. 
This  class  of  symptoms  may  be  due  to  a  variety  of  causes — hepatic  congestion, 
perihepatitis,  soreness  of  muscles  from  vomiting,  and  in  some  cases  actual  in- 
flammation of  the  liver.  Urinary:  In  high  degrees  of  toxemia  unsynthetized 
nitrogen  compounds  appear  in  the  urine  at  the  expense  of  the  urea  (ammonia 
compounds,  amino-acids,  purin  bodies).  In  some  cases  leucin  may  be  present  as 
a  result  of  destruction  of  liver  tissue.  Generally  speaking,  the  urinary  findings 
in  the  toxemia  of  pregnancy  are  sufficiently  numerous  and  varied  to  discourage 
classification.  They  tend  to  show  that  various  phases  of  hepatic  insufficiency 
may  occur  irrespective  of  other  changes.  Nervous:  This  class  of  symptoms 
is  characteristic  of  the  toxic  state.  Alteration  of  character  may  be  of  the  same 
nature  as  the  moody,  peevish,  and  irascible  "spells"  which  result  from  bilious 
crises.  An  increase  in  reflex  excitability  may  account  for  some  of  the  mor- 
bidity of  the  gravida.  In  higher  types  of  toxemia  an  increase  of  cortical  activity 
is  shown  by  intense  restlessness,  agitation,  insomnia,  convulsions,  delirium,  etc. 
This  class  of  symptoms  may  be  followed  or  replaced  by  the  opposite  group — 
apathy,  hebetude,  somnolence,  stupor  and  coma.  Headache  may  be  mentioned 
in  this  connection.  In  some  cases  the  nerves  are  directly  attacked  by  a  circulat- 
ing poison  (polyneuritis).  Cutaneous:  Several  cutaneous  symptoms  of  pre- 
sumably toxic  origin — pigmentation,  pruritus,  etc. — are  discussed  in  the  section 
on  Skin  Diseases  in  Pregnancy  (page  337).  The  relationship  of  the  pernicious 
impetigo  herpetiformis  to  the  toxemia  of  pregnancy  has  not  been  determined. 
Ewing  regards  it  as  belonging  here.  Although  heretofore  looked  upon  as  a 
septic  condition  with  metastases  to  the  skin, — death  occurring  usually  from 


296  PATHOLOGICAL  PREGNANCY. 

pneumonic  deposits, — the  prominence  of  vomiting  as  a  symptom  is  worthy  of 
mention,  as  suggestive  of  the  autotoxic  state.  Jaundice  in  the  gravida  is  a 
subject  of  unusual  interest.  Despite  the  frequency  of  hepatic  insufficiency  in 
the  gravida,  icterus  appears  to  be  quite  rare,  and  when  present  due  in  some 
cases  to  mere  coincidence,  as  simple  obstruction,  etc. 

Clinical  Types. — The  clinical  picture  of  the  toxemia  of  pregnancy  varies 
greatly  with  the  intensity  of  the  intoxication;  but  whatever  its  degree,  it  resem- 
bles markedly  the  various  symptoms  of  hepatic  insufficiency  in  the  non-pregnant. 
The  mild,  self-limited  form,  comprising  the  so-called  petty  morbidity  of  the  first 
half  of  pregnancy,  as  seen  especially  in  primigravidae,  agrees  in  a  measure  with 
so-called  "  biliousness  "  or  "  hepatism."  The  gastro-intestinal  symptoms  com- 
prise nausea,  vomiting,  various  forms  of  indigestion,  anorexia,  constipation,  etc.; 
the  nervous  and  cerebral  symptoms  comprise  nervous  irritability,  apathy,  de- 
pression, alterations  of  character,  hysteria,  headache,  vertigo,  etc.  Chloasma 
and  pruritus  are  common. 

The  highest  or  most  intense  degree,  constituting  the  so-called  acute  (including 
fulminant)  toxemia  of  pregnancy,  agrees  closely  with  the  profound  toxemia  which 
accompanies  acute  parenchymatous  hepatitis  and  acute  yellow  or  red  atrophy 
of  the  liver.  Vomiting  is  severe  and  incessant,  and  "  black  vomit  "  is  often 
present.  The  cerebrum  is  profoundly  affected.  Intense  headache  occurs.  At 
the  outset  we  usually  find  increased  motor  activity  manifested  by  restlessness, 
anxiety,  insomnia,  which  symptoms  pass  readily  into  delirium,  maniacal  excite- 
ment, and  convulsions.  This  stage  of  excitation  passes  in  turn  into  somnolence, 
stupor,  and  coma.  In  exceptionally  severe  cases  there  is  no  stage  of  excite- 
ment, the  patient  developing  stupor  and  coma  at  the  outset.  Excitation  and 
depression  appear  to  alternate  in  some  cases.  In  acute  toxemia  the  urine  almost 
always  shows  evidence  of  greatly  disturbed  metabolism,  nitrogen  retention,  albu- 
minuria, presence  of  leucin  and  tyrosin,  etc.,  etc.,  and  often  of  actual  renal 
lesions.  The  patient  nearly  always  succumbs,  and  quickly — usually  in  a  few 
days,  and  often  within  forty-eight  hours  or  even  less. 

Betw^een  the  acute  and  mild  forms  we  find  every  degree  of  intensity.  The 
so-called  pre-eclamptic  state  represents  a  severe  but  not  necessarily  pernicious 
form  of  toxemia,  which  very  often  yields  to  timely  treatment.  Similar  states 
occur  early  in  pregnancy  and  without  any  connection  with  eclampsia,  and  while 
alarming,  may  still  respond  to  treatment.  A  moderately  severe  toxemia  appears 
prone  to  attack  some  one  group  of  organs  and  set  up  a  peculiar  train  of  symp- 
toms. Hence  we  encounter  such  well-marked  clinical  syndromes  as  pernicious 
vomiting,  eclampsia,  psychoses,  polyneuritis,  etc.,  all  of  which  are  considered 
by  themselves. 

Course,  Termination,  and  Sequels. — The  acute  toxemia  is  probably  in- 
variably fatal,  although  recovery  seems  to  have  occurred  from  analogous  condi- 
tions in  the  non-pregnant.  While  it  tends  to  destroy  the  patient  rapidly,  it  has 
been  known  exceptionally  to  persist  for  months.  Death  usually  occurs  within 
a  week  after  the  supervention  of  the  nervous  stage,  and  may  result  in  a  few  days 
or  even  hours. 

Fetal  death  or  emptying  the  uterus  appears  to  exert  no  salutary  effect;  nor 
is  the  condition  amenable  to  disintoxicating  methods,  or  to  any  treatment  what- 
ever. Persistence  through  and  beyond  the  puerperal  state  could  only  occur  as 
a  rare  exception,  death  being  none  the  less  inevitable. 

The  course  and  termination  of  subacute  toxemia  are  discussed  under  Nausea 
and  Vomiting  of  Pregnancy,  Polyneuritis  and  Eclampsia. 

Mild  or  benign  toxic  symptoms  often  cease  spontaneously  in  the  course  of 


TOXEMIA   OF  PREGNANCY.  297 

pregnancy  itself,  and  in  any  case  they  usually  disappear  after  delivery.  Ewing 
states  that  in  some  cases  hepatic  insufficiency  persists  after  delivery.  The 
commonest  actual  sequelae -consist  of  blood  changes;  paralysis  following  neuritis ; 
and  occasional  nephritis  developed  from  pregnancy-kidney.  Ewing  believes  that 
puerperal  sepsis  may  often  be  practically  a  sequela  of  the  toxemia  of  pregnancy, 
through  furnishing  a  strong  predisposition  to  infection. 

Diagnosis. — Here  are  comprised  the  recognition  of  the  various  degrees  of 
hepatic  insufficiency,  beginning  with  the  mild  or  benign  types  and  ending  with 
complete  paralysis;  the  recognition  of  the  various  associated  blood-states; 
and,  finally,  the  characterization  of  the  particular  clinical  type.  It  is  therefore 
requisite  in  all  suspected  cases  to  make  a  physical  examination  of  the  liver  and 
spleen,  and  to  have  the  urine  analyzed  by  an  expert,  with  special  reference  to 
the  detection  of  unsynthetized  nitrogenous  bodies,  and  organic  acids.  The 
patient  may  be  tested  on  alimentary  glycosuria.  It  is,  of  course,  highly  im- 
portant to  measure  the  work  of  the  kidneys.  In  theory,  a  blood  examination 
should  be  valuable,  but  the  simpler  tests  would  not  yield  much  information, 
while  a  quantitative  or  physico-chemical  analysis  would  not  be  possible  in 
routine  work.  The  nervous  system  should  be  examined,  because  the  degree  of 
nervous  instability  is  a  factor  of  importance,  and  the  disposition  of  the  toxemia 
to  attack  the  higher  nerve-centers  must  be  borne  in  mind.  Further,  it  is  im- 
portant to  recognize  the  evidence  of  a  hysterical  element  when  this  is  present; 
also  mechanical  factors  and  chance  complications. 

Whenever  a  pregnant  woman  is  taken  violently  ill,  we  must  always  bear  in 
mind  the  possibility  of  a  fulminant  type  of  the  toxemia  of  pregnancy.  It 
is  here  that  the  condition  is  usually  misunderstood;  and  mysterious  cases 
of  sudden  death,  alleged  suicides  or  accidental  poisonings,  supposed  instances 
of  acute  meningitis  or  of  fulminant  infectious  disease,  may  perhaps  have  been 
examples  of  the  most  intense  degree  of  toxemia  of  pregnancy.  To  make  an 
exact  diagnosis  in  these  cases  may  not  be  possible. 

In  an  ordinary  case  of  the  acute  type  a  diagnosis  should  be  made  from  a 
physical  examination  of  the  liver,  and  the  results  of  the  urinary  analyses,  together 
with  the  rational  signs. 

In  the  rare  cases  in  which  the  liver  appears  normal  or  the  urinary  examina- 
tion is  negative  the  diagnosis  is  of  course  difficult.  In  these  anomalous  cases  the 
patient  may  appear  to  suffer  from  some  profound  infection  or  intracranial  disease. 

The  diagnosis  of  the  subacute  types  of  toxemia  will  be  considered  under 
Hyperemesis,  Eclampsia,  Polyneuritis,  etc. 

Recognition  of  the  milder  degrees  of  toxemia  demands  no  special  considera- 
tion. Whenever  a  woman  vomits  persistently  her  urine  should  be  examined 
for  evidences  of  faulty  metabolism,  as  shown  by  the  percentages  of  total  nitro- 
gen excreted  as  urea  nitrogen,  ammonia  nitrogen,  kreatinin  nitrogen,  uric  acid 
nitrogen,  and  tmdetermined  nitrogen.  A  toxemic  state  is  often  first  indicated 
by  departures  from  the  normal  standard,  as  high  ammonia  nitrogen  percentage 
or  undetermined  nitrogen  percentage  of  the  total  nitrogen. 

Mere  diminution  of  the  percentage  of  urea  does  not  signify  nitrogenous  re- 
tention, for  the  total  nitrogen  is  distributed  among  the  urea,  ammonia,  kre- 
atinin, uric  acid,  amino-acid,  etc. ;  and  while  under  normal  conditions  over  80 
per  cent,  of  the  nitrogen  occurs  in  the  form  of  lirea,  certain  urines  often  con- 
tain very  large  percentages  of  ammonia-nitrogen  and  correspondingly  low  ones 
of  urea.  Diet  and  elimination  of  nitrogen  by  the  bowel  must  always  be  con- 
sidered in  this  connection.  Increased  percentage  of  ammonia-nitrogen  is  not 
pathognomonic  of  toxemia  of  pregnancy,  but  may  be  viewed  with  suspicion. 


298  PATHOLOGICAL  PREGNANCY. 

My  experience  embraces  62  urinalyses  for  the  nitrogen  partition  in  24 
patients,  and  does  not  permit  me  to  formulate  rules  for  a  guide  to  the  diag- 
nosis of  an  impending  or  existing  pregnancy  toxemia.  However,  in  most  of 
my  cases  examined,  faulty  metabolism,  as  determined  from  urinalyses  of 
twenty-four  hour  specimens  of  urine  for  total  nitrogen  and  its  coefhcients, 
coexisted  with  clinical  symptoms  of  toxemia. 

Prognosis. — This  is  good  in  the  benign  forms  of  toxemia.  In  the  acute 
and  fulminant  types  the  prognosis  is  nearly  hopeless,  since  the  mortality  has  been 
almost  universal.  For  the  prognosis  of  eclampsia,  hyperemesis,  etc.,  see  subse- 
quent sections.  Richard  C.  Norris*  -is  inclined  to  regard  some  cases  of  sudden 
death  in  the  puerperium  as  due  to  cardiac  failure  induced  by  the  direct  action 
of  the  autotoxic  blood-state  upon  the  cardio-vascular  system. 

Treatment. — As  for  prophylaxis,  a  woman  who  seems  to  suffer  much  con- 
stitutional reaction  during  menstruation  should  be  carefully  watched  during 
gestation.  Charcot  states  that  a  functionally  incompetent  liver  is  very  likely 
to  be  inherited ;  therefore  a  woman  whose  ancestors  and  kindred  show  a  marked 
tendency  to  "hepatism"  would  run  more  risk  in  becoming  pregnant  than  one 
without  this  ancestry.  Finally,  a  woman  in  whom  symptoms  of  toxemia  appear 
to  persist  during  the  period  of  lactation  should  by  all  means  avoid  a  second  con- 
ception until  complete  recovery  has  occurred.  For  other  resources  read  sec- 
tion on  Etiology. 

The  curative  treatment  demands  a  careful  study  of  the  symptoms  in  all  cases, 
and  prompt  action  in  most.  Mild  toxemia,  so  called,  requires  only  expectant 
management. 

Despite  the  apparently  hopeless  outlook  in  acute  toxemia,  I  strongly  recom- 
mend in  all  cases  the  same  general  line  of  treatment  as  that  I  set  down  for  the 
Preventive  Treatment  of  Eclampsia.  (See  pages  308  and  309.)  In  addition 
to  the  exclusive  milk  diet,  and  the  stimulation  of  the  action  of  the  liver, 
bowels,  kidneys,  skin,  and  lungs,  I  have  found  repeated  colonic  irrigation  and 
infusion,  and  intravenous  infusion  of  the  decinormal  saline  fluid,  valuable. 
On  account  of  the  diminished  alkalescence  of  the  blood,  alkalies  are  indicated 
in  theory,  as  they  are  in  diabetic  coma,  in  which  state  they  have  produced  some 
benefit.  Bearing  in  mind  that  the  hepatic  lesion  may  in  a  given  case  be  due  in 
part  to  a  bacillus,  methylene-blue,  which  is  eliminated  by  the  bile,  should  be 
of  value  as  an  antiseptic. 

My  views  upon  the  evacuation  of  the  uterine  contents  are  the  same  here  as 
in  the  Preventive  Treatment  of  Eclampsia. 

Conclusion. — It  will  be  asked,  no  doubt,  "Why  devote  so  much  space  in  a 
text-book  to  a  condition  like  the  acute  toxemia  of  pregnancy,  which  apparently 
is  rare,  and  can  seldom  be  foreseen,  and,  thus  far,  has  almost  resisted  treatment? " 
My  answer  is,  that  it  represents  a  phase  of  our  knowledge  which  is  in  its  infancy, 
and  a  subject  which  will,  in  my  belief,  come  in  time  to  throw  light  on  many 
dark  places  in  obstetrics.  Acute  toxemia  of  pregnancy  is  not  as  rare  by  any 
means  as  is  generally  believed,  and  is  a  most  insidious  affection  when  it  does 
occur,  masking  itself,  as  it  does,  under  various  clinical  pictures. 

If  unrecognized,  it  may  lead  to  a  suspicion  of  poisoning,  suicide,  or  some  other 
type  of  preventable  death.  We  might,  in  a  general  way,  compare  the  recog- 
nition of  this  state  with  the  'discovery  of  ptomaines  and  ptomaine  poisoning, 
in  regard  to  practical  significance.  Again,  it  may  some  time  be  possible  to  fore- 
see, prevent,  and  cure  this  condition  when  not  of  the  fulminant  type.     Recovery 

*  "  Effects  of  the  Toxemia  of  Pregnancy  upon  the  Cardio-vascular  System,"  "Amer. 
Jour.  Obstet.,"  July,  1903,  pp.  31,  104. 


NAUSEA  AND  VOMITING  IN  THE  PREGNANT  WOMAN.       299 

is  not  uncommon  after  acute  phosphorus-poisoning,  thereby  showing  the  regener- 
ative power  of  the  liver. 

2.  Nausea  and  Vomiting  in  the  Pregnant  Woman. — This  subject  is  considered 
under  the  toxemia  of  pregnancy  largely  because  in  fatal  cases  hepatic  lesions 
of  the  same  character  as  those  which  occur  in  eclampsia  and  acute  yellow 
atrophy  of  the  liver  may  usually  be  found;  also  because  severe  vomiting  is  a 
prominent  symptom  of  many  toxemias.  If  vomiting  in  the  pregnant  is  fre- 
quently spoken  of  as  hysterical  in  character,  it  must  be  borne  in  mind  that 
this  refers  only  to  the  clinical  expression  of  the  condition. 

(i)  Simple  (So-called  Physiological)  Vomiting. — Slight  nausea,  with 
or  without  vomiting,  occurs  in  about  one-half  of  all  pregnancies,  and  in  the 
vast  majority  of  primiparas;  the  symptom  appears  about  the  end  of  the  first 
month,  and  is  usually  associated  with  perversions  of  taste.  There  may  be 
general  anorexia,  repugnance  to  certain  articles  of  diet,  and  unnatural  cravings 
for  others  not  usually  appetizing.  Considered  in  their  totality,  symptoms  refer- 
able to  the  digestive  tract  are  almost  universally  present  in  pregnancy;  those 
who  escape  nausea  or  perversions  of  taste  and  anorexia  may  suffer  from  hyper- 
orexia  or  bulimia.  These  symptoms  usually  persist  until  the  middle  of  the 
fifth  month,  when  they  subside  spontaneously,  and  appetite  and  normal  tastes 
return. 

In  their  simplest  expression  the  nausea  and  vomiting  of  pregnancy  bear  a 
notable  resemblance  to  the  morning-vomiting  of  the  alcoholic  subject,  appearing 
as  a  rule  upon  rising  from  the  recumbent  position.  Retching  may  be  the  only 
active  symptom,  or  actual  vomiting  of  mucus,  gastric  juice,  or  biliary  matter 
may  occur.  The  woman  is  usually  able  to  eat  breakfast,  and  has  no  further 
gastric  disturbance  during  the  day.  In  rare  instances  the  nausea  and  vomit- 
ing occur  in  the  latter  part  of  the  day  or  during  the  night.  In  the  next  higher 
degree  the  woman  vomits  during  or  after  the  meal.  She  is,  however,  usually 
able  to  continue  eating  and  to  retain  the  food ;  so  that  there  is  no  real  interfer- 
ence with  nutrition. 

In  a  still  higher  degree  nausea  is  more  than  a  momentary  affair,  and  persists 
for  several  hours,  often  accompanied  by  ptyalism  and  distress  in  the  epigastric 
region;  vomiting  is  then  slow  to  occur,  and  is  much  more  distressing  than  usual. 
In  all  degrees  up  to  this  point  there  is  no  necessary  interference  with  nutrition, 
and  no  absolute  refractoriness  to  treatment.  " 

(2)  Hyperemesis. — When  vomiting  is  sufficiently  persistent  or  distressing 
to  demand  active  treatment,  the  term  hyperemesis  is  employed  to  distinguish 
it.  In  a  woman  suffering  from  this  degree  of  vomiting  there  is  a  tendency  to 
aggravation  of  the  symptoms  and  interference  with  nutrition. 

Vomiting  of  pregnancy  sometimes  pursues  an  anomalous  course,  without 
regard  to  its  severity.  Thus,  it  may  begin  immediately  after  conception,  as  if 
it  were  an  expression  of  suppressed  menstruation.  The  ordinary  appearance  of 
vomiting  coincides  with  the  period  of  the  second  (suppressed)  menstrual  period. 
The  usual  time  of  cessation  of  vomiting  corresponds  to  "quickening"  of  the 
fetus.  In  a  few  cases  the  disappearance  of  vomiting  may  be  succeeded  by 
diarrhea.  It  has  also  been  noted  that  a  strong  mental  impression  about  this 
time  will  cause  the  sudden  cessation  of  vomiting.  In  a  small  proportion  of 
cases  the  latter  symptom  is  prolonged  to  term,  and  in  another  series  of  cases 
the  gastric  disturbances  set  in  about  the  middle  of  pregnancy.  This  relation 
to  suppressed  menstruation,  with  the  occasional  resemblance  to  the  morning 
vomiting  of  alcoholic  subjects,  suggests  the  presence  of  a  toxic  element,  even 
in  so-called  physiological  and  benign  degrees  of  vomiting;    as  does  also  the 


300  PATHOLOGICAL  PREGNANCY. 

coexistence  of  numerous  symptoms  mentioned  under  Mild  Toxemia  of 
Pregnancy.     (See  page  296.) 

Most  standard  authorities,  including  gastro-intestinal  specialists,  continue  to 
refer  benign  vomiting  of  pregnancy  to  uterine  irritation,  due  to  compression  of 
the  uterine  nerves  by  the  growing  uterus  in  general,  added  to  abnormal  uterine 
distention,  malpositions,  cervicitis,  etc.,  in  particular.  Reflex  vomiting  some- 
times occurs  in  pelvic  affections  of  the  non-pregnant.  But  it  is  generally  ad- 
mitted that  an  increased  nervous  excitability  furnishes  a  predisposition ;  and  we 
must  not  forget  that  this  exalted  sensibility,  wherever  found,  is  itself  attributed 
by  many  to  an  autotoxic  state  of  the  same  nature  as  that  which  is  produced 
by  nervous  exhaustion.  Quite  recently  Dr.  M.  Knapp,  of  New  York,  has  denied 
the  existence  of  reflex  vomiting. 

Treatment. — Benign  vomiting  may  be  relieved  by  simple  measures,  such  as 
breakfast  in  bed  before  assuming  the  erect  posture;  the  use  of  concentrated 
liquid  food;  anesthesia  of  the  stomach  by  a  few  drops  of  laudanum;  readily 
digestible  solid  food;  sparkling  wines,  or  alkaline  effervescent  waters;  aromatics; 
cracked  ice,  etc.  After  eating,  recumbency  should  be  maintained.  Recent 
clinical  experience  has  caused  me  to  look  with  suspicion  upon  even  benign 
vomiting,  as  the  expression  of  a  mild  toxemia  of  pregnancy,  and  to  treat  it 
accordingly,  namely,  by  a  restricted  diet;  stimulating  the  action  of  the  liver, 
bowels,  skin,  and  lungs,  and  by  colonic  irrigation  and  infusion. 

(3)  Incoercible  or  Pernicious  Vomiting. — These  terms  are  applied  re- 
spectively to  vomiting  which  is  rebellious  to  all  treatment,  and  that  which  is  in 
any  way  a  menace  to  life  or  which  has  a  grave  prognostic  significance.  Several 
entirely  different  conditions  may  be  included  here.  Thus,  in  the  gravida,  as  in 
the  non-gravida,  vomiting  may  be  purely  symptomatic  in  character,  although 
doubtless  aggravated  and  given  a  peculiar  character  through  the  gravid  state, 
which  predisposes  the  woman  to  nausea  and  vomiting.  Thus,  these  symptoms 
may  be  due  to  intercurrent  gastritis  and  other  severe  organic  diseases  of  the 
stomach;  the  passage  of  gall-stones,  intestinal  obstruction,  peritonitis,  menin- 
gitis, etc.,  etc.  Symptomatic  vomiting  will  be  referred  to  again  under  "  Diag- 
nosis." 

Essential  vomiting  of  pregnancy  is  of  two  distinct  types  : 

(a)  Autotoxic  Type  is  a  manifestation  of  the  toxemia  of  pregnancy  and  is 
accompanied  by  other  severe  symptoms  of  that  condition,  chiefly  headache 
motor  cortical  excitement  (agitation,  restlessness,  insomnia,  convulsions,  deli- 
rium), or  apathy,  stupor,  and  coma.  Vomiting  in  this  condition  is  violent, 
incessant,  and  characterized  in  its  later  stages  by  hematemesis,  the  vomited 
matter  having  a  coffee-grounds  appearance  (black  vomit).  The  patient  does 
not  perish  of  vomiting,  however, — i.e.,  as  a  result  of  inanition  or  exhaustion, — 
but  of  the  profound  toxemia  as  affecting  the  blood  and  higher  nerve-centers. 
The  vomiting,  however,  may  be  termed  pernicious,  because  of  its  grave  prog- 
nostic significance,  especially  when  "  black  vomit  "  is  present.  In  this  type, 
unless  recovery  can  be  brought  about,  death  usually  occurs  within  two  or  three 
weeks  at  the  most,  and  often  within  a  few  days.  Exceptionally,  the  condition 
may  persist  for  many  weeks,  so  that  transitions  occur  between  this  and  the 
following  type,  and  in  a  certain  number  of  cases  the  two  are  indistinguishable, 
save  when  in  case  of  death  an  autopsy  clears  up  the  situation.  The  toxic 
nature  of  a  case  is  then  shown  by  evidences  of  the  hepatic  lesions  of  the 
toxemia  of  pregnancy. 

(b)  Non-toxic  Type. — The  other  type  of  essential  vomiting  of  pregnancy  is 
known  as  the  non-toxic  or  inanition  type.     Death  occurs  here  purely  from  star- 


NAUSEA  AND  VOMITING  IN  THE  PREGNANT  WOMAN.       301 

vation,  the  patient  living  for  a  number  of  weeks,  during  which  period  the  prog- 
nosis depends  greatly  on  the  ability  of  the  medical  attendant  to  control  the 
vomiting. 

The  inanition  type  of  vomiting,  including  certain  cases  in  which  the  toxemia 
of  pregnancy  cannot  be  fully  excluded,  is  so  well  known  as  to  present  certain 
classical  features. 

Etiology. — A  hysterical  or  neurotic  substratum  is  often  in  evidence  through 
the  numerous  spontaneous  and  induced  stigmata  and  symptoms  of  these  condi- 
tions. Reflex  excitability  is  also  a  powerful  factor  in  determining  the 
paroxysms  of  vomiting,  and  we  therefore  sometimes  find  evidences  of  a  causal 
connection  between  various  lesions  and  malpositions  of  the  uterus  and  the 
emesis. 

Symptoms. — For  convenience,  these  are  usually  divided  into  three  stages. 
First  stage:  A  condition  beginning  as  hyperemesis — usually  in  the  first  two 
months,  but  exceptionally  during  the  sixth  or  seventh  month — soon  becomes 
incoercible  by  ordinary  medical  measures,  and  the  complete  rejection  of  the 
ingesta  brings  about  more  or  less  emaciation.  During  this  stage  the  symptoms 
may  often  be  controlled  by  special  treatment,  or  may  even  cease  spontaneously. 
Second  stage:  The  pulse  becomes  small  and  feeble,  the  skin  hot  and  dry,  con- 
stipation is  extreme,  and  albuminuria  appears  with  casts.  There  are  progress- 
ive emaciation  and  weakness.  This  stage  may  be  prolonged  for  weeks,  and  at 
any  time  during  this  period  induction  of  labor  or  fetal  death  may  save  the 
patient's  life,  although  in  a  certain  proportion  of  cases  emptying  the  uterus  is 
without  effect.  Third  stage:  This  period  indicates  that  the  patient  has  become 
too  weak  to  rally,  even  if  vomiting  ceases,  which  event  often  occurs.  Pre- 
monitions of  death  are  numerous,  and  to  these  are  superadded  cerebral  symp- 
toms— headache,  delirium,  stupor,  etc.  Death  usually  results  from  coma. 
These  cerebral  symptoms  have  no  connection  with  the  toxemia  of  pregnancy, 
but  are  connected  with  progressive  inanition  and  possibly  with  the  constant 
waste  of  gastric  juice,  which  in  animals  is  known  to  produce  death  amid  similar 
symptoms. 

Diagnosis. — We  must  be  certain  that  the  woman  is  actually  pregnant, 
bearing  in  mind  that  pernicious  vomiting  may  begin  almost  as  soon  as  concep- 
tion itself;  and  also  that  the  emesis  is  not  the  result  of  an  organic  disease  of 
the  stomach,  brain,  kidneys,  pancreas,  intestines,  peritoneum,  etc.  We  must 
then  exclude  the  toxemia  of  pregnancy,  which  is  by  no  means  easy  in  the  milder 
forms  of  the  latter,  and  is  doubtless  often  impossible  at  the  outset.  Hyper- 
emesis, associated  with  the  so-called  benign  or  petty  manifestations  of  toxemia 
(see  p.  296),  need  not  be  toxic  itself.  As  a  general  rule,  toxic  vomiting  is 
associated  with  other  severe  symptoms  of  toxemia. 

Prognosis. — This  is  good  rather  than  bad  if  proper  treatment  is  instituted 
sufficiently  early.  If  a  toxic  element  is  present,  the  prognosis  depends  in  a 
large  degree  upon  the  early  termination  of  pregnancy.  Under  other  circum- 
stances artificial  abortion  is  practised  only  as  a  last  resort.  A  severe  first 
stage,  passing  rapidly  into  the  second  stage,  is  a  rather  unfavorable  prognostic; 
and  after  the  second  stage  is  reached  a  marked  daily  loss  of  weight — over  10 
ounces  (300  c.c.) — and  the  presence  of  the  diazo-reaction  have  a  serious  prog- 
nostic value.      The  prognosis  for  the  fetus  at  or  near  term  is  relatively  good. 

Treatment. — Although  I  am  not  convinced  that  all  cases  of  pernicious  vomit- 
ing of  pregnancy  have  an  autotoxic  origin,  still  I  believe  that  a  large  proportion 
of  these  cases  are  due  to  hepatic  insufficiency  and  toxemia,  and  that  the  best 
results  will  be  obtained  by  treatment  directed  to  this  cause.     Hence  while 


302  PATHOLOGICAL  PREGNANCY. 

not  ignoring  entirely  the  Value  of  hygienic,  dietetic,  medicinal,  and  even  local 
treatment,  I  advise  that  treatment  be  promptly  directed  to  the  correction  of 
an  hepatic  insufficiency  and  toxic  blood-state,  whether  the  clinical  picture  of 
the  toxemia  of  pregnancy  is  present  or  not.  Regulate  the  diet,  and  if  neces- 
sary, nourish  by  rectal  feeding;  stimulate  the  liver  and  bowels  by  a  full  dose 
of  calomel,  and  secure  the  action  of  the  drug  by  high  enemata  of  sulphate  of 
magnesia;  secure  free  action  of  the  kidneys  by  diuretics,  the  free  ingestion  of 
plain  water  or  colonic  infusion  of  decinormal  saline  solution;  cause  the  skin  to 
act  with  hot  packs  and  use  oxygen  freely  for  the  lungs.  Frequently  repeated 
colonic  irrigation  and  infusion  are  most  valuable  to  relieve  the  toxemia  or  hepatic 
insufficiency  and  the  intense  thirst  so  often  present.  Likewise  in  severe  cases 
intravenous  infusion  of  the  saline  solution  will  prove  valuable,  and  it  should 
be  resorted  to  early  and  repeated  if  necessary.  My  views  upon  the  evacuation 
of  the  uterine  contents  are  the  same  here  as  in  the  Preventive  Treatment  of 
Eclampsia. 

The  hygiene  of  the  patient  should  be  carefully  regulated;  kind  treatment  and 
pleasant  surroundings  are  of  the  greatest  value;  sexual  intercourse  is  to  be  pro- 
hibited; in  grave  cases  the  patient  should  remain  in  bed  and  perfect  quiet  and  rest 
be  enjoined.  Many  cases  can  be  improved  if  the  patients  can  be  made  unconscious 
of  the  fact  of  swallowing,  either  by  spraying  the  fauces  with  a  solution  of  cocain  or 
bv  the  use  of  the  esophageal  tube.  Liqmd  food,  such  as  milk  and  lime-water,  eggs, 
beef -juice,  koumyss,  or  clam-broth,  should  be  tried;  and  if  moderate  quantities 
are  rejected,  the  food  should  be  given  in  teaspoonful  doses  at  short  intervals; 
at  times  it  is  most  acceptable  if  given  with  cracked  ice,  in  other  cases  very  hot 
milk  or  broths  are  retained.     Somatose  and  panopepton  are  of  value. 

Medicinal. — Among  the  medicines  that  are  useful  are  the  oxalate  of  cerium, 
in  doses  of  from  five  to  ten  grains  (0.3  to  0.6  gm.),  with  or  without  the  subnitrate 
of  bismuth;  iodine  (Churchill's  tincture),  one  or  two  drops  well  diluted;  menthol 
and  cocain,  either  as  a  spray  or  internally,  in  small  doses ;  carbonic-acid  water, 
in  small  quantities  or  ad  libitum;  the  same  with  the  addition  to  each  siphon  of  a 
drachm  (4  gm.)  of  the  bromide  of  potassium;  tincture  of  nux  vomica  in  ten-drop 
doses  for  gastric  catarrh,  and  pepsin  with  diluted  muriatic  acid  after  food.  Klein- 
wachter  uses  creosote,  15  minims  (i  gm.)  three  times  a  day,  combined  with  citrate 
of  caffein  and  gentian,  as  an  intestinal  antiseptic.  The  inhalation  of  oxygen 
is  serviceable  even  early  in  the  disease.  Nerve  sedatives  are  sometimes  very 
useful;  the  bromide  of  potassium  or  of  sodium,  with  or  without  chloral,  may  be 
given  in  full  doses  per  rectum.  Codein  may  be  given  by  the  mouth  or  morphin 
hypodermatically;  the  latter  may  be  given  en  dermatic  ally  over  the  epigastrium 
when  local  tenderness  exists.  Other  remedial  agents  are  counter-irritation 
or  the  ether  spray  over  the  epigastrium,  or  the  appHcation  of  ice  to  the  cervical 
vertebrae.  Cases  of  success  by  the  use  of  the  electric  current  have  been  reported, 
the  faradic  current  being  passed  through  the  stomach.  Believers  in  the  hysteri- 
cal theory  apply  the  measures  which  are  most  efficacious  in  the  treatment  of 
that  affection.  Thus,  the  woman  may  be  separated  from  her  friends  and  relatives 
and  placed  in  a  sanitarium.  Sometimes  the  mere  threat  of  isolation  has  pro- 
duced a  cure. 

Local. — Malpositions  of  the  uterus,  and  engorgement  or  hypertrophy  of  the 
cervix",  should  be  corrected;  erosions  may  be  touched  with  a  10  per  cent,  solu- 
tion of  silver  nitrate  or  with  pure  carboHc  acid ;  the  apphcation  of  cocain  to  the 
cervix  and  the  vault  of  the  vagina  has  been  reported  to  be  successful  in  some 
cases.  I  have  never  found  it  of  value.  Dilatation  of  the  internal  os  with  a 
glove-stretcher  dilator,  so  as  thoroughly  to  rupture  the  circular  fibers  at  this 


ICTERUS.  303 

point,  is  occasionally  a  successful  procedure.  At  the  same  time  any  endo- 
trachelitis,  or  erosions  of  the  portio  vaginalis,  should  be  attended  to.  I 
have  found  that  attention'  to  these  matters  has  apparently  effected  a  cure. 
I  have  dilated  the  internal  os  in  primigravidas,  curetted  the  cervical  canal, 
scraped  the  cervix  itself  free  from  erosions,  applied  pure  carbolic  acid  to  the 
cervix  and  canal,  and  relieved  the  symptoms,  without  interrupting  pregnancy, 
in  a  number  of  cases  given  up  as  hopeless  and  sent  to  the  hospital  to  have  labor 
induced.  The  finger  will  occasionally  serve  as  a  dilator,  and  in  every  case  the 
greatest  care  must  be  used  not  to  rupture  the  membranes. 

Induction  of  Labor. — This  will  become  "  necessary  when  there  appears  no 
other  way  of  saving  the  mother,  but  we  must  never  wait  too  long  before  resort- 
ing to  this  means,  for  although  the  vomiting  always  stops  with  the  evacuation 
of  the  uterus,  the  woman  may  die  from  exhaustion. 

Rectal  Feeding. — This  may  become  necessary,  and  should  not  be  delayed  too 
long.  The  physician  must  ever  bear  in  mind  that  rectal  alimentation  has  its 
time  limit,  that  it  cannot  be  continued  for  weeks,  as  some  suppose;  for  during 
this  time  the  patient  grows  progressively  weaker,  and  the  induction  of  labor  is 
finally  resorted  to,  too  late  to  save  the  mother's  life.  Rectal  feeding  has  been 
attended  with  variable  results  in  the  vomiting  of  pregnancy.  Most  commonly 
the  injections  have  consisted  of  beef -tea,  albumin  water,  defibrinated  blood, 
brandy,  milk,  and  peptones.  A  few  drops  of  laudanum  are  sometimes  added. 
Rectal  injections  must  be  given  in  small  quantities,  not  more  than  five  or  six 
ounces,  for  fear  of  causing  local  irritation.  At  times  the  mere  efforts  of  vomiting 
are  so  great  as  to  cause  the  expulsion  of  the  enema.  The  rectum  should  first  be 
cleansed  by  the  injection  of  a  quart  of  water  containing  a  teaspoonful  of  salt. 
One  hour  after  the  resulting  evacuation  the  first  rectal  feeding  should  be 
given.  Any  kind  of  a  syringe  may  be  connected  with  a  soft-rubber  rectal  tube 
and  'the  nutriment  thrown  slowly  into  the  bowel.  The  tube  is  then  withdrawn 
and  the  patient  instructed  to  lie  quietly,  in  order  that  the  enema  may  be  retained. 
Three  to  five  nutrient  injections  of  from  five  to  ten  ounces  may  be  given  daily.  The 
following  substances  are  recommended  for  feeding:  (i)  Commercial  peptones  and 
propeptones,  two  or  three  ounces  in  each  injection.  Commercial  beef-juices.  (2) 
Milk  and  egg,  a  sort  of  eggnog,  containing  six  or  seven  ounces  of  milk  and  one 
or  two  raw  eggs,  a  teaspoonful  of  powdered  sugar,  a  large  pinch  of  salt,  and  a 
tube  of  Fairchild's  pancreatin.  (3)  Pancreatized  meat,  five  ounces  of  minced 
raw  beef,  one  or  two  of  fresh  pancreas,  an  ounce  of  butter,  and  six  ounces  of  water, 
all  well  compounded.  These  enemata  should  be  given  in  rotation.  In  addition, 
the  body  receives  a  supply  of  water  by  daily  rectal  injection  of  saline  infusion.* 
Pancreatized  milk  made  with  Fairchild's  pancreatin  may  be  used,  also  defibrin- 
ated blood.  Flint's  formula — milk  2  ounces  (60  c.c),  whisky  half  an  ounce 
(15  c.c),  with  one  half  of  an  egg — may  be  used.  Leube's  pancreatic  meat 
emulsion  is  a  good  preparation:  3  to  10  ounces  (90  to  300  c.c.)  of  very  finely 
chopped  beef,  one-third  the  quantity  of  minced  pancreas  (pig  or  ox),  with  the 
addition  of  lukewarm  water  and  mixed  in  a  mortar  to  the  consistency  of  a  thick 
soup.  After  each  rectal  injection  the  patient  should  retain  the  recumbent  posi- 
tion on  the  left  side  with  hips  raised,  for  a  time,  while  the  nurse  supports  the 
anal  region  with  a  towel.  Posenheim's  formula  is:  glucose  half  an  ounce;  2 
€ggs;  peptone  i  to  2  drachms,  and  half  an  ounce  of  emulsion  of  cod-liver  oil. 
Six  per  cent,  solution  of  cocain  should  be  applied  to  painful  hemorrhoids. 

3.  Icterus. — Icterus  being  but  a  symptom  and  very  infrequent  as  a  com- 
plication of  the  toxemia  of  pregnancy,  I  do  not  give  it  special  consideration. 
*  Einhom:   "Post-Graduate,"  New  York,  July,  1900. 


304  PATHOLOGICAL  PREGNANCY. 

Frequent  references  to  the  subject  will  be  found  under  "  The  Toxemia  of 
Pregnancy." 

4.  Eclampsia. — See  a'so  Toxemia  of  Pregnancy. — Definition. — By  the  terms 
eclampsia,  puerperal  eclampsia,  and  puerperal  convulsions,  is  meant,  in  modern 
medicine,  an  acute  morbid  condition,  making  its  advent  during  pregnancy,  labor, 
or  the  puerperal  state,  which  is  characterized  by  a  series  of  tonic  and  clonic  con- 
vulsions, affecting  first  the  voluntary  and  then  the  involuntary  muscles,  accom- 
panied by  complete  loss  of  consciousness,  and  ending  in  coma  or  sleep.  The 
disease  may  eventuate  in  death  or  recovery  (Charpentier).  Eclampsia  may  be 
gestational,  intra-partum,  and  post-partum,  or  puerperal  eclampsia  proper. 

Frequency. — Eclampsia  occurs  most  often  in  the  latter  part  of  gestation, 
less  often  in  labor,  and  least  of  all  in  the  puerperium.  The  estimation  of 
its  frequency  has  been  variously  tabulated  as  i  in  500  pregnancies,  i  in  250 
to  300,  I  in  350  to  500 — a  variation  of  from  2  per  cent,  to  4  per  cent.  The  com- 
plication is  stated  to  appear  in  i  per  cent,  of  all  cases  of  albuminuria  of  preg- 
nancy. Schauta  believes  it  to  occur  in  25  per  cent,  of  all  pregnancies.  I  found 
in  1200  cases  of  confinement,  800  of  which  were  out-patient  cases,  that  eclampsia 
occurred  in  7  cases,  or  0.58  per  cent.,  or  i  in  171  cases.  In  another  series  of 
1000  hospital  cases  it  occurred  in  3  cases,  or  0.30  per  cent.,  or  once  in  333  cases. 
Of  the  10  cases,  8  occurred  at  the  tenth  month,  i  at  the  sixth,  and  i  at  the  fifth. 

Etiology  and  Pathology. — Eclampsia  may  be  regarded  as  due  to  the  auto- 
toxic  state  of  pregnancy  as  manifested  chiefly  in  the  latter  months.  For  some 
reason,  at  present  unknown,  the  autotoxic  state  has  a  special  tendency  at  that 
period  to  attack  the  renal  organs,  and  lead  to  the  so-called  kidney  of  pregnancy, 
which  in  its  essential  form  is  a  temporary  fatty  infiltration  of  the  parenchyma 
of  that  organ  that  disappears  after  delivery.  In  higher  degrees  of  toxemia  the 
kidneys  undergo  changes  analogous  to  those  of  the  liver  in  acute  parenchymatous 
hepatitis  and  acute  yellow  atrophy.  (See  Toxemia  of  Pregnancy,  p.  292.)  In 
rare  instances  pregnant  women  who  are  suffering  from  antecedent  Bright 's 
disease  develop  uremia  before  delivery,  this  naturally  simulating  ordinary 
eclampsia' (see  "Diagnosis");  but  this  is  the  exception.  Authorities  who  are 
only  familiar  with  autopsy  findings  deny  the  existence  of  an  essential  pregnancy 
kidney,  for  in  fatal  cases  we  see  the  more  severe  lesions — acute  parenchymatous 
nephritis  with  epithelial  necrosis,  renal  atrophy,  chronic  nephritis  in  various 
degrees,  etc.  But  the  existence  of  an  essential  pregnancy  kidney  is  shown  by 
the  fact  that  something  like  75  per  cent,  of  all  cases  of  eclampsia  recover,  the 
urine,  shortly  after  delivery,  showing  no  abnormalities. 

The  autotoxic  state  when  manifested  late  in  pregnancy,  as  the  forerunner 
of  eclampsia,  is  not,  as  a  rule,  of  the  higher  degrees;  but  the  alterations  present 
in  the  pregnancy  kidney,  while  not  destructive,  are  sufficient  to  impair  the  renal 
functions,  so  that  a  vicious  circle  is  established  in  which  the  condition  of  the 
blood  and  metabolism,  by  their  action  upon  the  kidney,  lead  to  a  reaction  on 
the  part  of  the  latter  upon  the  former.  Hence,  ordinary  eclampsia  may  be 
regarded  as  a  complicated  affair — a  moderately  severe  toxemia  plus  renal  in- 
adequacy. When  the  toxemia  is  of  such  severity  as  to  cause  marked  destruc- 
tive lesions  of  the  kidney,  death  rapidly  supervenes — not  from  the  urinary 
suppression,  but  from  the  intense  basic  toxemia  through  its  immediate  action 
upon  the  blood-state  and  the  cerebral  cortex.  The  conditions  are  not  essentially 
different  from  those  in  which  the  patient  dies  of  fulminant  toxemia  without 
renal  complications  of  any  sort. 

In  the  majority  of  cases  of  eclampsia,  in  which  we  feel  sure  of  the  existence 
of  the  pregnancy  kidney,  it  is  stated  that  hepatic  lesions  are  almost  invariably 


ECLAMPSIA.  305 

present,  although  these  may  be  minimal  and  demonstrable  only  with  the  micro- 
scope. (See  Toxemia  of  Pregnancy,  p.  291.)  However,  the  majority  of  these 
cases  do  not  come  to  autopsy.  In  higher  and  usually  fatal  degrees  of  toxemia, 
when  the  renal  lesions  are  presumably  severe  and  destructive,  the  hepatic 
lesions  may  or  may  not  be  in  proportion  to  the  toxemia.  In  rare  instances  the 
kidneys  may  be  practically  destroyed  with  little  or  no  evidence  of  hepatic 
lesions. 

To  sum  up,  the  pathological  findings  of  eclampsia  necessarily  embrace  those 
of  the  basic  autotoxic  state,  plus  the  alterations  incidental  to  the  pregnancy 
kidney.  The  cerebral  lesions — hyperemia,  oedema,  thrombosis,  hemorrhages — 
are  doubtless  aggravated  by  the  repeated  convulsions  and  perhaps  by  the  heroic 
remedies  demanded  by  therapeutic  indications.  This  may  also  be  true  of  the 
myocardial  degeneration  and  bronchopneumonia,  which  some  pathologists 
include  among  the  autopsy  findings. 

Diihrssen  and  others  describe  a  mild  type  of  eclampsia,  without  any  evidences 
of  toxemia  or  urinary  abnormalities.      They  term  this  reflex  eclampsia. 

The  predisposing  and  exciting  causes  of  eclampsia  enumerated  in  the  older 
text-books  have  little  force  to-day.  We  are  in  complete  ignorance  concerning 
the  tendency  of  the  disease  to  develop  late  in  pregnancy,  in  connection  with 
primiparity,  prematurity,  twin  gestation,  and  the  like;  and  are  equally  ignor- 
ant as  to  reasons  for  the  frequency  of  post-partum  eclampsia  (18  per  cent.), 
and  for  the  persistence  of  convulsions  after  emptying  the  uterus  in  something 
like  40  per  cent,  of  cases.  In  regard  to  exciting  causes  they  do  not  differ  from 
those  in  convulsive  disorders  in  general,  where  reflex  excitability  is  necessarily 
present  in  high  degree. 

Symptomatology . — The  symptoms  of  eclampsia  may  be  considered  under 
the  prodromal  period,  or  pre-eclamptic  state,  and  those  occurring  during  the 
attack.  In  the  latter  there  are  three  stages:  (i)  invasion;  (2)  tonic  and  clonic 
convulsions;  (3)  coma.  Prodromal  period,  or  pre-eclamptic  state:  The  symp- 
toms of  this  stage  are  very  important,  for  they  offer  a  certain  warning  of  an 
impending  attack.  There  may  be,  as  in  epilepsy,  a  well-defined  aura.  After 
this,  or  even  without  it,  there  may  be  headache,  tinnitus  aurium,  visceral  dis- 
turbances, such  as  dizziness,  amblyopia,  amaurosis,  epigastric  pain,  digestive 
and  nervous  disturbances,  and  a  feeling  of  general  debility.  These  are  fairly 
constant  in  about  one-fourth  of  all  cases  of  eclampsia.  At  times  there  may 
be  symptoms  of  involvement  of  the  brain,  stupor  or  insomnia,  vertigo,  vomiting, 
mental  excitement,  or  despondency.  These  may  all  disappear,  in  which  case 
there  is  a  return  of  appetite,  a  more  abundant  perspiration  and  diuresis,  and 
the  patient  falls  into  a  refreshing  sleep.  Generally,  however,  the  result  is 
not  so  favorable,  and  the  premonitory  signs,  or  pre-eclamptic  state,  after  last- 
ing for  several  hours  or  days,  give  place  to  those  of  the  stage  of  invasion.  There 
is  convulsive  twitching  of  the  lids,  the  eyes  stare,  and  the  pupils,  which  were 
at  first  contracted  to  a  pin-point,  are  widely  dilated.  During  the  attack  there 
is  total  insensibility  to  light.  The  face  is  cyanotic,  and  there  is  rapid  and 
convulsive  jerking  of  the  muscles  about  the  alae  of  the  nose  and  the  mouth. 
The  mouth  is  contracted  to  one  side,  there  are  rotation  of  the  head  and  rolling 
up  of  the  eyeballs.  This  is  followed  by  the  stage  of  tonic  and  clonic  convul- 
sions. The  movements,  which  at  first  concerned  only  the  head,  now  extend 
to  the  neck,  trunk,  and  extremities,  very  infrequently,  however,  passing  to 
the  lower  extremities.  The  neck  is  bent  backward,  and  at  last,  together  with 
the  back,  forms  an  opisthotonic  curve;  there  are  extension  and  rigidity  of 
the  arms,  clenching  of  the  hands,  with  the  thumbs  in  the  palms,  and  flexing 
20 


306 


PATHOLOGICAL  PREGNANCY. 


of  the  knees  on  the  abdomen.  The  respiratory  muscles,  including  the  dia- 
phragm, are  involved  by  the  tonic  convulsions.  Although  the  muscles  of  the 
chest  are  firmly  contracted,  there  may  be  one  or  two  spasmodic  respirations 
at  the  height  of  the  paroxysm.  The  tongue  partly  protrudes  and,  since  it 
is  often  bitten,  the  saliva,  which  is  frothy,  is  colored  with  blood.  There  is 
complete  loss  of  sensation  and  of  consciousness.  The  duration  of  the  tonic  con- 
vulsions is  from  ten  to  twenty  seconds,  and  they  are  followed  by  clonic  spasms. 
The  clonic  convulsions,  as  in  the  first  of  the  attack,  begin  in  the  face,  which 
becomes  horribly  distorted,  and  then  extend  over  the  body.  Irregular  and 
noisy  respiration  takes  place,  there  are  rapid  opening  and  closing  of  the  jaws, 
and  the  tongue  may  be  again  bitten.  The  patient  may  have  to  be  held  in 
bed,  but  generally  the  body  retains  its  previous  position.  Eclampsia  closely 
follows  epilepsy  in  many  clinical  features.  Thus,  there  are  overlapping  (sub- 
intrant)  convulsions,  a  status  convulsivus  or  continuous  paroxysmal  state  (status 
epilepticus,  status  eclampticus),  and  an  exhaustion-paralysis  or  temporary  loss 


Fig.  470. — Segment  of  Liver  showing  TTemorrhagic  Hepatitis  in  Eclampsia  (Actual 
Size). — (From  a  specimen  in  the  Pathological  Laboratory  of  the  Cornell  University  Medi- 
cal College.) 


of  motor  power  in  the  convulsed  muscles  in  both  diseases.  At  the  end  of  the 
attack  full,  labored,  and  stertorous  respiration  occurs.  In  one  or  two  minutes 
follows  the  stage  of  coma.  The  duration  of  this  period  is  about  half  an  hour. 
Consciousness  and  sensation  are  slow  to  return.  If  a  favorable  issue  is  to  take 
place,  the  patient  falls  into  a  deep  sleep,  and  awakes  to  ask  confusedly  what 
has  happened.  After  this  stage  mothers  have  denied  their  offspring  born  dur- 
ing eclampsia.  Rarely  there  is  but  a  single  attack,  and  as  a  rule  a  number 
occur  at  varying  intervals.  If  the  seizures  cannot  be  controlled,  and  death 
is  inevitable,  there  are  a  progressive  rise  of  temperature  to  104°  F.  (40°  C.) 
or  more,  and  a  small,  rapid,  wiry  pulse.  A  semi-unconscious  state  follows, 
and  death  may  occur  during  this  period,  or  in  the  course  of  an  attack,  from 
pulmonary  oedema,  cerebral  congestion,  hemorrhage,  or  exhaustion.  Patients 
who  have  survived  the  disease  proper  may  die  during  the  puerperium  of  some 
intercurrent  affection. 

The  Effect  upon  the  Fetus  and  Labor. — One  attack  is  often  sufficient  to  kill  the 


ECLAMPSIA.  307 

child.  In  twin  pregnancy  the  death  of  one  or  both  children  may  occur.  How- 
ever, the  child  may  survive  several  attacks.  Winckel  notes  an  interesting  fact, 
that  if  the  fetus  is  killed- and  pregnancy  not  interrupted  immediately,  labor 
both  in  its  onset  and  course  may  be  free  from  convulsions.  In  view  of  the 
shock,  nervous  disturbance,  and  uterine  contractions,  there  is  apt  to  be  an 
abrupt  termination  of  pregnancy.  If  the  attack  takes  place  in  labor,  there 
is  increase  of  the  pains  from  general  muscular  excitement,  so  that  the  child 
may  be  born  while  the  physician  is  engrossed  with  the  care  of  the  mother. 
There  is  involvement  of  the  kidneys  in  about  two-thirds  of  the  cases  of  eclamp- 
sia. In  84  per  cent,  the  urine  contains  albumin,  varying  in  quantity  even 
to  2.5  per  cent.,  or  higher.  There  are  an  increase  of  albuminuria  with  each 
attack,  and  a  rapid  decrease  after  its  subsidence.  As  a  prodrome  this  is  im- 
portant. The  urine  generally  contains  sugar  and  formed  elements,  red  and 
white  corpuscles,  as  well  as  casts;  that  is,  there  are  present  symptoms  of 
acute  congestion  of  the  kidney. 

Diagnosis. — Convulsive  affections  other  than  typical  eclampsia  may  occur 
during  pregnancy.  Some  of  these  stand  in  some  near  relationship  to  eclampsia, 
while  others  do  not.  Thus,  acute  toxemia  of  pregnancy  may  be  associated  with 
incidental  or  terminal  convulsions,  which  may  or  may  not  resemble  those  of 
typical  eclampsia.  When  the  resemblance  is  marked,  yet  without  evidences  of 
renal  disorder,  the  condition  is  termed  cholemic  eclampsia,  because  accompanied 
by  the  picture  of  acute  hepatic  insufficiency.  Atypical  convulsions  may  or 
may  not  accompany  the  most  acute  type  of  acute  toxemia  of  pregnancy  (p.  296). 
Finally,  in  women  with  nephritis  who  become  pregnant,  true  uremic  convulsions 
may  occur,  although  the  reverse  is  usually  the  case.  Typical  eclampsia,  due  to 
secondary  renal  lesion,  is  readily  distinguished  from  the  other  forms  enumerated 
by  the  pre-eclamptic  stage,  the  progressive  character  of  the  convulsions  with 
increasing  temperature,  the  evidences  of  renal  impairment,  the  response  to 
proper  treatment,  etc.,  etc.  There  is  probably  no  guide,  nor  is  there  any  great 
necessity  for  differentiation  between  atypical  eclampsia  and  the  convulsions  due 
essentially  to  the  toxic  state  of  pregnancy,  for  the  conditions  are  closely  alHed. 
Uremia  is  distinguished  from  eclampsia  chiefly  by  the  absence  of  fever,  and  also 
by  a  history  of  Bright 's  disease;  but  the  distinction  is  not  of  great  importance, 
for  the  treatment  of  the  two  conditions  is  practically  the  same.  It  must  be 
borne  in  mind  that  eclampsia  without  convulsions  may  occur,  i.  e.,  evidences  of 
pregnancy-kidney,  pre-eclamptic  state,  oedema,  retinitis,  etc.,  may  not  be  fol- 
lowed by  convulsions,  but  instead  pass  directly  into  stupor.  Such  a  condition 
is  extremely  rare,  but  not  difficult  to  understand  when  we  bear  in  mind  that  in 
some  cases  of  atypical  eclampsia  very  few  convulsions  occur. 

Of  convulsive  states  which  may  simulate  eclampsia  without  being  allied  to 
it,  are  epilepsy  and  hysteria  major,  on  the  one  hand,  and  the  convulsions  of 
acute  intercurrent  diseases  {meningitis,  for  example)  on  the  other.  Epilepsy 
and  hysteria  should  not  be  accompanied  by  toxemic  phenomena,  and  the  dis- 
tinction ought  to  be  readily  made.  The  status  epilepticus  and  status  hysteri- 
cus might,  by  reason  of  their  continuous  convulsions,  stupor,  high  temperature, 
etc.,  readily  simulate  eclampsia,  although  the  history  of  the  case  should  clear 
up  the  obscurity.  The  convulsions  of  meningitis  are  local,  while  those  of 
eclampsia  are  general.  Apoplexy  rarely  occurs  in  pregnancy.  There  are  no 
prodromes.     Coma  quickly  follows. 

Prognosis. — In  10  cases  of  eclampsia  occurring  among  2200  cases  of  labor  I 
found  the  maternal  mortality  was  2  cases,  or  20  per  cent.  Of  the  viable  chil- 
dren, all  lived.     Puerperal  eclampsia  is  still  a  very  grave  affection.     Many  statis- 


308  PATHOLOGICAL  PREGNANCY. 

tics  show,  even  at  the  present  time,  a.  maternal  mortality  of  30  per  cent.,  while 
that  of  the  child  reaches  50  per  cent.  There  is  imminent  danger  of  a  seizure 
in  the  pregnant  woman  who  shows  marked  symptoms  of  toxemia,  albuminuria, 
and  the  quantity  of  whose  urine  is  gradually  decreasing.  The  danger  becomes 
more  pronounced  in  proportion  to  the  increase  of  the  albumin,  the  decrease  of 
the  water  excreted  in  the  twenty-four  hours,  and  the  departure  of  the  nitrogen 
compounds  of  the  urine  from  their  normal  standard  indicates  faulty  metabolism. 
As  these  conditions  are  reversed,  to  a  corresponding  extent  the  peril  becomes 
more  remote.  The  amount  of  urea  excreted  is  a  more  important  factor  in  prog- 
nosis than  that  of  albumin,  as  has  been  clearly  shown  by  Bouchard  and  Davis. 
Davis  discovered  that  the  symptoms  of  toxemia  decrease  with  the  increase  of 
urea.  The  gravity  of  the  prognosis  increases  in  proportion  to  the  early  stage  of 
pregnancy  at  which  the  convulsion  occurs.  It  has  been  demonstrated  by  Schauta 
many  times  that  all  derangements,  ev^en  those  of  renal  origin,  subside  after  the 
child's  death;  thus  the  prognosis  will  improve  in  repeated  attacks  in  proportion  to 
the  early  occurrence  of  its  death.  Profuse  sweating,  especially  of  early  occur- 
rence, is  a  favorable  sign.  The  prognosis  becomes  most  unfavorable  when 
the  seizures  take  place  in  pregnancy,  when  they  follow  one  another  rapidly^ 
when  they  become  gradually  more  pronounced,  and  when  they  have  existed 
for  an  extended  period  before  assistance  can  be  obtained.  Mortality  has  been 
decreased  by  chloroform  treatment  in  these  cases.  Briefly,  the  prognosis  is 
favorable  when:  (i)  The  attacks  are  far  apart  and  not  severe.  (2)  The  child 
perishes.  (3)  The  patient  has  conscious  intervals  between  the  attacks.  (4)  The 
quantity  of  albumin  is  small.  (5)  Decrease  of  temperature  occurs.  (6)  The 
seizures  take  place  in  advanced  labor  or  during  the  puerperium..  Prognosis 
is  not  favorable  when  opposite  conditions  exist. 

The  vitality  of  a  child  born  of  an  eclamptic  mother  is  below  normal,  and  it 
often  dies  in  the  first  twenty-four  hours.  The  mother  may  succumb  from  ex- 
haustion; cerebral  apoplexy  due  to  forcible  rupture  of  the  vessels;  asphyxia 
caused  by  spasm  of  the  glottic  and  respiratory  muscles ;  oedema  of  the  lungs 
or  of  the  brain,  following  a  serous  effusion  from  overcharged  capillaries;  con- 
gestion of  the  brain,  in  which  coma  is  the  chief  symptom;  or  cardiac  paralysis. 
The  last,  when  taking  place  during  the  general  convulsion,  is  followed  by  instant 
death.  The  child's  death  may  be  due  to  maternal  convulsions  and  the  pres- 
sure resulting  therefrom;  asphyxia,  caused  by  compression  or  oedema  of  the 
placenta,  or  an  extreme  amount  of  carbon  dioxide  in  the  blood;  or  it  may 
be  by  direct  poisoning  by  the  toxins  in  the  maternal  circulation. 

Treatment. — The  best  etiological  theory  of  the  present  day,  although  it  may 
not  be  correct  in  all  details,  is  that  eclampsia  is  due  to  toxemia.  Taking  this 
for  granted,  then,  the  prophylactic  treatment  of  eclampsia  is  far  more  im- 
portant than  the  curative,  since  it  is  usually  possible  to  prevent  the  attack. 
Many  prominent  American  as  well  as  foreign  obstetricians  hold  this  opinion. 

The  Preventive  Treatment. — The  pre-eclamptic  symptoms  comprise  a  rapid 
pulse,  generally  accompanied  by  high  arterial  tension;  anorexia,  gastrointestinal 
derangements;  mental  and  physical  lassitude;  headache;  decrease  of  all  the 
excretions,  both  solid  and  hquid,  either  gradual  or  rapid;  that  is,  just  those 
disturbances  that  might  be  expected  from  the  introduction  or  retention  in 
the  circulation  of  some  toxin.  The  quantity  of  urine  excreted  in  twenty- 
four  hours  is  not  always  to  be  depended  upon  as  an  exact  guide  to  renal 
failure.  As  has  been  stated,  albuminuria  may  be  wanting  before,  during, 
and  even  after  an  eclamptic  convulsion.  (See  Toxemia  of  Pregnancy.) 
The    eclamptic    tendency    increases    proportionately    with    the    advance    of 


ECLAMPSIA.  309 

pregnancy  and  the  consequent  increased  fetal  metabolism.  Besides,  it  is 
well  known  that  the  mortality  of  the  mother  decreases  gradually  from  the 
ante-partum  to  the  postrpartum  condition;  that  is,  it  is  maximum  when 
the  onset  of  eclampsia  occurs  during  pregnancy,  diminished  during  labor,  and 
is  minimum  when  the  seizure  takes  place  for  the  first  time  after  the  child  is 
born.  Thus  statistics  tabulated  by  Green  *  show  the  maternal  mortality  in 
ante-partum  eclampsia  to  be  46  per  cent.;  fetal  mortality,  69  per  cent.; 
in  intra-partum  eclampsia,  maternal  mortality,  25  per  cent.;  fetal  mor- 
tality, 25  per  cent.;  in  post-partum  eclampsia,  mortality  of  mother  7  per  cent. 
There  is  offered,  from  the  present  knowledge  of  the  etiology  of  puerperal  eclamp- 
sia, at  least  a  working  hypothesis — namely,  the  early  recognition  of  the  pre- 
eclamptic stage.  In  addition  to  the  monthly  or  bi-monthly  examination  of 
the  urine  for  the  detection  of  albumin,  something  more  is  needed,  since  non- 
albuminuric  eclampsia  exists  in  from  9  to  16  per  cent,  of  cases,  and  it  seems 
quite  as  fatal  as  albuminuric  eclampsia,  sometimes  more  so.  In  addition  to  the 
physical  signs  of  decided  kidney  inadequacy,  as  an  index  of  impending  eclamptic 
seizure,  we  should  watch  for  the  general  symptoms  of  a  circulation  overcharged 
with  poisonous  material — high  arterial  tension,  headache,  dizziness,  gastric  dis- 
orders, mental  and  physical  lassitude;  and  for  disturbances  of  the  bowels,  liver, 
skin,  and  lungs,  and  their  failure  properly  to  perform  their  functions,  in  order  that 
the  patient  may  be  intelligently  treated.  Under  these  conditions  only  is  the  whole 
duty  of  the  physician  to  the  patient  accomplished.  The  following  is  the  line 
of  treatment  suggested  by  me  for  this  state:  (i)  The  amount  of  nitrogenous 
food  should  be  diminished  to  a  minimum.  (2)  The  production  and  absorption 
of  poisonous  materials,  in  the  intestines  and  body-tissues,  should  be  limited  and 
their  elimination  should  be  aided  by  improving  the  action  of  (a)  the  bowels,  (b) 
the  kidneys,  (c)  the  liver,  (d)  the  skin,  and  (e)  the  lungs.  (3)  The  source  of  the 
fetal  metabolic  products,  and  the  peripheral  irritation  in  the  uterus  should,  if  neces- 
sary, be  removed  by  evacuating  that  organ.  The  first  indication,  reduction  of  the 
quantity  of  nitrogenous  food,  can  be  best  met  by  an  exclusive  milk  diet,  to 
which,  as- the  symptoms  improve,  fish  and  white  meats  may  be  added.  It  is 
more  agreeable  to  the  patient,  and  a  safer  course  to  pursue,  to  begin  at  once 
with  an  absolute  milk  diet,  than  to  compromise,  and  later  to  institute  a  strict 
milk  diet.  An  abundant  supply  of  pure  air  and  water  must  be  offered  for  the 
second  indication,  that  of  elimination.  To  this  maybe  added  gentle  exercise  or 
light  calisthenics,  or  even  massage,  in  some  instances.  In  treating  the  bowels 
the  writer  advises  the  use  of  daily  doses  of  colocynth  and  aloes  at  bedtime,  fol- 
lowed by  a  saline  the  next  morning.  For  the  liver,  I  find  efficacious  an  occa- 
sional dose  of  calomel  and  soda  at  bedtime,  followed  in  the  morning  by  one  of 
the  stronger  sulphur  waters,  as  Rubinat,  Villacabras,  or  Birmensdorf.  Large 
doses  of  glonoin  are  excellent  to  increase  diuresis.  To  encourage  the  function 
of  the  skin,  the  body  should  be  clothed  in  wool  or  flannel,  massage  may  be 
used,  and,  according  to  the  severity  of  the  case,  the  warm  bath,  hot  bath, 
hot  pack,  or  hot-air  bath  may  be  resorted  to.  A  definite  diaphoretic-diuretic 
action,  together  with  the  additional  prompt  effect  upon  the  liver  and  intes- 
tines, is  obtained  by  the  following  treatment:  A  tablet  composed  of  calomel, 
digitalis,  and  squill,  each  i  gr.  (0.06  gm.),  and  muriate  of  pilocarpin,  -5^-g-  gr. 
(0.003  mg.),  is  given.  The  next  morning  a  full  dose  of  Villacabras  water  is 
administered.  Thus  four  of  the  five  eliminative  processes  are  urged  to  per- 
form their  functions  more  energetically.     I  approve  of  the  use  of  jaborandi 

*  Green:  "Puerperal  Eclampsia;  Experience  of  the  Boston  Lying-in  Hospital  in  the 
Last  Eight  Years,"  "  Amer.  Jour,  of  Obstet.,"  1893,  28,  18-44. 


310  PATHOLOGICAL  PREGNANCY. 

in  the  pre-eclamptic  state,  provided  there  is  no  pronounced  cardiac  disease, 
although  it  has  been  generally  abandoned  as  a  diaphoretic  during  the  eclamptic 
seizure.  Inhalations  of  oxygen  are  beneficial  when  a  sufficient  supply  of  fresh 
air  is  wanting,  and  in  cases  in  which  exercise  cannot  be  taken.  Some  prepara- 
tion of  iron  is  indicated,  as  Basham's  mixture,  or  the  tincture  of  the  chloride. 
Each  case  must  be  treated  individually;  no  absolutely  definite  rules  can  be 
followed;  but  the  preceding  suggestions  comprise  the  general  hygienic  and 
medicinal  treatment  of  the  pre-eclamptic  state.  In  certain  cases  a  restricted 
diet  and  gentle  stimulation  of  the  functions  of  the  kidney  and  intestines  are 
sufficient,  and  the  patient  may  be  allowed  a  certain  freedom,  even  exercise 
in  the  open  air,  the  skin  being  protected  by  wool  or  flannel.  In  more  severe 
cases  of  eliminative  insufficiency  the  patient  must  be  kept  perfectly  quiet 
in  bed,  allowed  only  a  strict  milk  diet,  while  all  of  the  eliminative  organs  must 
be  stimulated  in  order  to  remove  the  symptoms  of  impending  eclampsia. 
However,  it  should  be  thoroughly  understood  that  the  milk  diet  is  the  corner- 
stone of  the  preventive  treatment  of  puerperal  eclampsia,  the  hygienic  and 
medicinal  treatment  being  only  of  secondary  importance.  In  a  case  in  which, 
despite  an  exclusive  milk  diet  and  the  energetic  stimulation  of  the  five  elimi- 
native processes,  the  symptoms  and  signs  of  the  pre-eclamptic  state  still  per- 
sist, or  at  any  time  become  urgent,  abortion  or  artificial  premature  labor  is 
indicated.  The  ideas  of  those  authorities  (especially  of  the  British  school 
of  midwifery)  who  do  not,  in  the  presence  of  urgent  symptoms,  approve  of 
inducing  labor  in  the  pre-eclamptic  state  are  difficult  to  understand.  How- 
ever, attention  must  be  paid  to  the  arguments  that  labor  induced  by  the  usual 
methods  increases  reflex  excitability  and  precipitates  convulsions ;  that  by 
such  methods  the  patient's  fate  is  sealed  before  delivery,  on  account  of  the 
time  necessary  to  eliminate  the  barrier  of  the  cervix;  and,  lastly,  that  the 
patient's  danger  is  increased  by  the  onset  of  labor.  In  reply,  it  may  be  stated 
that  the  methods  of  terminating  the  pregnancy  advised  here  need  not  neces- 
sarily increase  reflex  excitability,  and,  should  they  do  so,  it  is  easy  to  control 
the  excitability  for  the  time  necessary  to  attain  our  ends;  that  the  necessary 
time  is  generally  very  short;  and,  indeed,  that  at  the  present  time  the  onset 
of  labor  and  the  termination  of  pregnancy  may  be  practically  synchronous, 
and  that  there  is  consequently  no  extended  or  tedious  labor  to  exert  its  un- 
favorable reactions  upon  the  patient.  Byers  *  made  the  objection  that,  on 
account  of  the  necessary  manipulation,  induced  labor  increases  the  risk  of 
sepsis.  This,  however,  should  not  prevent  the  modem  obstetrician  from  under- 
taking the  operation  when  he  is  assured  of  being  surgically  clean.  Charles, 
of  the  Li6ge  Maternity,  gave  statistics  at  the  International  Congress  of  Ob- 
stetrics and  Gynecology  in  1896  which  were  greatly  in  favor  of  this  procedure, 
of  induced  labor,  when  prophylaxis  fails  or  the  pre-eclamptic  symptoms  become 
urgent.  His  table  demonstrates  that  every  mother  recovered  and  75  per  cent, 
of  the  children  lived.  I  strongly  advise  a  quick  manual  dilatation  of  the  os  in 
these  cases ;  only,  however,  after  the  cervical  canal  is  in  a  condition  suitable  for 
its  safe  performance.  I  would  also  insist  upon  a  complete  dilatation  of  the  os, 
before  the  operator  undertakes  to  deliver  the  patient. 

The  Curative  Treatment. — An  eclamptic  seizure  presents  a  desperate  con- 
dition. From  various  parts  of  the  world  the  most  recent  statistics  continue 
to  estimate  the  maternal  mortality  at  from  25  to  35  per  cent.  Rational  curative 
treatment  of  this  affection  will  remain  impossible  as  long  as  its  pathology 
continues  obscure.  From  experience  no  one  treatment  can  be  recommended 
*Intemat.  Congress  of  Obstet.  and  Gynecology,  Geneva,  Sept.,  1896. 


ECLAMPSIA.  311 

for  all  cases.  No  matter  what  treatment  may  be  pursued,  many  women  recover, 
many  die  in  spite  of  treatment,  while  others  do  well  with  no  treatment  at  all. 
No  one  treatment,  then,  can  be  advised;  each  case  must  be  attacked  in  accord- 
ance with  the  existing  indications.  A  combined  treatment  gives  better  promise 
than  a  single,  for  preserving  the  lives  of  mother  and  child,  in  the  event  of  an 
eclamptic  attack.  For  this  combined  treatment  the  three  following  indications 
are  offered:  (i)  Control  the  convulsions;  (2)  eliminate  the  poison  or  poisons 
which  we  presume  cause  the  convulsions;  (3)  empty  the  uterus  under  deep 
anesthesia,  by  some  method  that  is  rapid  and  that  will  cause  as  little  injury 
to  the  patient  as  possible.  These  indications,  though  stated  in  the  order  of 
their  importance,  still  may  be  carried  out  synchronously.  In  another  class 
of  cases  the  first  and  second  indications  should  be  fulfilled,  while  the  physician 
waits  for  a  suitable  moment  to  undertake  the  third.  The  second  indication, 
elimination,  logically  accompanies  the  first  and  third,  and  should  be  under- 
taken at  the  same  time  with  them. 

1.  Control  of  the  convulsions.  The  most  effective  as  well  as  the  safest 
medicinal  anti-eclamptics  are  chloroform,  morphin  (hypodermatically),  vera- 
trum  viride,  and  chloral  hydrate,  the  latter  being  used  alone  or  in  com- 
bination with  the  bromide  of  sodium.  I  prefer  chloroform,  veratrum  viride 
and  chloral,  in  the  order  stated.  For  the  last  three  years  I  have  abandoned 
almost  entirely  the  use  of  morphin,  since  it  seems  to  prolong  the  post-eclamptic 
stupor,  while  it  increases  the  tendency  to  death  during  coma,  by  its  interference 
with  the  eliminative  processes.  The  most  reliable  of  all  agents  for  immediate 
control  of  the  convulsive  attacks  is  chloroform.  Veratrum  viride  in  efficiency 
stands  second  only  to  chloroform.  With  the  pulse  strong  as  well  as  rapid, 
it  offers  the  most  certain  means  at  our  command  for  temporarily,  and  even 
permanently,  controlling  the  spasms.  With  a  weak  pulse,  morphin  hypo- 
dermatically, inhalations  of  chloroform,  and  chloral  administered  per  rectum, 
together  with  stimulation,  if  necessary,  may  be  used  instead.  The  pulse-iate 
is  diminished  by  veratrum  viride,  and  convulsions  are  almost  unknown  when 
the  pulse-rate  is  60  or  under;  the  temperature  also  is  reduced,  and  the  rigidity 
of  the  cervical  rings  is  relaxed;  diaphoresis  and  diuresis  are  promptly  effected, 
so  that,  by  the  use  of  this  drug,  our  first  indication,  the  control  of  the  convul- 
sions, is  fulfilled  as  well  as  the  third,  the  elimination  of  an  unknown  toxin.  The 
initial  dose  of  the  tincture  of  veratrum  viride,  given  subcutaneously,  should 
be  generally  from  10  to  20  minims  (0.6  to  1.2  gm.);  an  additional  10  minims 
(0.6  gm.)  may  be  administered  by  the  same  method  every  succeeding  half- 
hour,  till  the  pulse  continues  below  60  to  the  minute.  While  under  the  influence 
of  the  veratrum,  the  patient  should  be  kept  in  a  recumbent  position.  Tumul- 
tuous heart-action  will  probably  supervene  when  the  erect  position  is  assumed. 
Whiskey  or  morphin  will  easily  control  vomiting  and  collapse,  if  they  occur. 
Rapid  evacuation  of  the  uterus  is  the  final  resort  for  the  control  of  the  con- 
vulsions. However,  it  might  be  stated  that  ice-bags  to  the  back  of  the  head 
and  neck  have  a  decided  effect  in  controlling  and  in  preventing  convulsive 
seizures. 

2.  Elimination  of  the  poison  or  poisons  which  are  presumed  to  cause  the  con- 
vulsions. The  following  means  may  be  advised  to  eliminate  the  poisonous 
material  from  the  blood  and  tissues.  Not  only  one,  but  all  of  the  eliminative 
organs  of  the  body  should  be  brought  into  play,  and- the  following  indication 
in  eclamptic  treatment  should  be  carried  out  along  with  the  two  previously 
described  methods.  As  early  and  prompt  catharsis  as  possible  should  be  ob- 
tained, by  means  of   croton  oil,  compound  jalap  powder,  or  calomel  followed 


312  PATHOLOGICAL  PREGNANCY. 

by  salines,  and  high  enemata  of  magnesium  sulphate.  The  writer  prefers 
to  treat  the  comatose  condition,  or  post-eclamptic  stupor  of  the  affection,  by 
repeated  doses  of  concentrated  solutions  of  magnesium  sulphate  or  Villacabras 
water,  administered  by  means  of  a  long  rectal  tube,  high  up  in  the  descending 
colon.  Hypodermatic  injections  of  the  sulphate  of  magnesium  have  been 
demonstrated  to  be  too  slow  and  ineffective  to  accomplish  any  good.  Dry 
or  wet  cups  over  the  kidneys,  followed  by  hot  fomentations,  is  an  excellent 
method  of  causing  diuresis.  Glonoin  is  invaluable  as  a  diuretic  and  anti- 
eclamptic,  the  latter  indication  being  fulfilled  by  diminished  arterial  tension. 
Veratrum  viride  stands  next  in  order  of  efficiency.  The  objects  of  its  admin- 
istration, at  this  time,  are  similar  to  those  in  the  pre-eclamptic  condition.  The 
hot-air  bath  or  the  hot  pack  encourages  diaphoresis,  the  writer  preferring  the 
former.  On  account  of  the  danger  of  pulmonary  and  glottis  oedema,  incident  to 
the  use  of  pilocarpin  as  a  diaphoretic,  in  the  existence  of  an  eclamptic  seizure, 
its  use  should  not  be  countenanced.  I  have  seen  improvement  result  from  vene- 
section-followed by  intravenous  saline  infusion,  thus  securing  a  cleansing  and 
disintoxication  of  the  blood  and  tissues.  Care  must  be  taken  that  no  great  dis- 
turbance of  the  blood-pressure  is  produced.  Thus,  in  cases  of  high  arterial 
pressure  the  amount  of  saline  should  not  exceed  and  may  even  be  less  than  the 
amount  of  blood  withdrawn.  I  have  also  obtained  satisfactory  results  by  ex- 
tended irrigation  of  the  lower  bowel,  using  either  decinormal  saline  solution  or 
sterile  water,  by  means  of  a  long,  single  or  return-flow  tube.  Collapse  attended 
by  a  small  compressible  pulse,  as  in  the  same  conditions  under  other  circum- 
stances, is  effectively  treated  by  the  introduction  into  the  blood  of  a  decinormal 
saline  solution.  Some  authorities  advocate  the  hourly  subcutaneous  injections 
of  ether  as  a  diuretic.  Abundant  administration  of  oxygen  is  invaluable  as  a 
general  stimulant,  to  assist  the  eliminative  function  of  the  lungs,  and  to  sustain 
life  in  post-eclamptic  stupor  or  coma.  Alcohol  is  often  a  necessary  stimulant, 
both  during  and  after  an  eclamptic  seizure,  and  strychnin  has  proved  effective 
in  the  post-partum  condition,  and  with  impending  collapse;  although,  reasoning 
from  a  physiological  standpoint,  it  would  seem  to  be  contraindicated. 

3.  Emptying  the  uterus  under  deep  anesthesia,  by  some  method  that  is  rapid  and 
that  will  cause  as  little  injury  to  the  woman  as  possible.  Careful  observations  seem 
to  show  that  danger  is  essentially  passed,  in  some  90  per  cent,  of  cases,  immedi- 
ately after  the  uterus  has  been  emptied,  if  this  is  accomplished  early  in  the  seizure. 
The  convulsions  do  not  always  cease  by  this  method,  but  they  become  less  dan- 
gerous, and  the  case  is  converted  to  one  of  post-partum  eclampsia,  in  which,  as 
has  been  stated,  the  mortality  is  only  7  per  cent.  It  seems  from  the  reports  of 
the  International  Congress  at  Geneva,  September,  1896,  and  from  the  literature 
of  the  last  ten  years,  that  the  best  authorities  are  in  favor  of  emptying  the 
uterus  as  quickly  as  possible,  in  cases  of  eclampsia,  whether  the  attack  takes 
place  before  or  during  labor,  although  the  opinion  as  to  the  method  to  be 
employed  varies  widely.  Nevertheless,  in  the  second  stage  of  labor,  after  securing 
dilatation,  all  are  agreed  that  there  is  indication  for  the  immediate  emptying  of 
the  uterus,  and  this  operation  should  be  promptly  performed.  This  is  accom- 
plished with  no  additional  danger  to  mother  or  child.  In  pregnancy  and  the 
first  stage  of  labor,  the  barrier  offered  to  rapid  delivery  is  the  undilated  cervix, 
and  it  is  just  here  that  obstetricians  hold  such  different  opinions  as  to  the  best 
plan  of  procedure.  Expectant  or  palliative  treatment  will  almost  surely  be  fol- 
lowed by  death  of  the  child,  and  about  one-third  of  the  mothers  succumb.  But 
if  the  uterus  is  promptly  evacuated  by  suitable  surgical  means,  the  child's  life  is 
preserved  and  the  mother  is  practically  subjected  to  no  danger.     During  preg- 


ECLAMPSIA. 


313 


nancy  and  early  labor  four  methods  are  suggested  for  quickly  emptying  the  uterus : 
(i)  Csesarean  section  (suprapubic  and  vaginal);  (2)  mechanical  dilatation  of  the 
cervix  (various  methods);  _(3)  deep  incisions,  which  at  once  completely  remove 
the  barrier  of  the  cervix;  (4)  combined  mechanical  dilatation  and  deep  cervical 
incisions.  A  high  mortality  (36.26  per  cent.,  according  to  the  figures  of  Char- 
pentier)  attends  the  first  method — Csesarean  section — for  the  relief  of  eclampsia. 
The  popular  method  of  the  present  day  seems  to  be  mechanical  dilatation  of  the 
cervix,  and  the  prompt  extraction  of  the  fetus.  This  method  is  safe  and  effec- 
tive when  properly  performed. 
However,  the  safe  performance  of 
this  method  will  demand  from 
forty  minutes  to  an  hour  and  a 
half  before  dilatation  is  well  ad- 
vanced. Certain  cervical  condi- 
tions, even  with  this  allowance  of 
time,  will  not  yield  to  manual  dila- 
tation, or  else  entail  lacerations  of 
the  lower  uterine  segment.  By 
the  third  method  of  delivery,  that 
of  deep  incision  of  the  cervix,  is 
presented  a  surgical  means  for 
emptying  the  uterus  in  from  five 
to  ten  minutes,  on  condition  that 
the  supravaginal  portion  of  the 
cervix  has  disappeared,  either  of 
itself  or  by  the  application  of  ap- 
propriate measures.  The  fourth 
method  comprises  a  combination 
of  the  second  and  third,  and  is 
suitable  for  cases  in  which  the 
supravaginal  portion  of  the  cer- 
vix has  not  disappeared,  and 
prompt  emptying  of  the  uterus  is 
indicated.  In  this  method  the  os 
is  mechanically  dilated  until  the 
internal  os  has  disappeared,  when 
the  dilatation  is  at  once  com- 
pleted by  means  of  the  incisions. 
There  are  few  statistics  to  offer 
concerning  the  results  of  the  third 
method  and  its  modification,  the 
fourth,  on  account  of  their  com- 
paratively recent  introduction. 
In    general,   the    indications    will 

be  fulfilled  by  a  prompt  manual  dilatation  of  the  os,  followed  by  extraction  of 
the  fetus;  however,  unless  this  can  be  expertly  carried  out,  with  an  intelligent 
understanding  of  the  mechanism  of  dilatation,  particularly  in  primiparas,  more 
favorable  results  will  be  attained  by  a  strictly  expectant  treatment.  Although  the 
mortality  is  greater  in  multiparae,  nevertheless,  puerperal  eclampsia  is  unfortu- 
nately four  times  more  frequent  in  primiparae.  The  cervix  uteri  consists  of 
muscle-fibers,  both  constricting  and  dilating,  and  while  it  is  known  that  labor  is 
generally  induced  by  the  first  convulsions,  nevertheless  the  supervening  asphyxia 


/niernalos 


£x€er/ia!  as. 


/ila^ider 


fb^in/z. 


Itectu 


Fig.  471. — Frozen  Section  of  the  Uterus  of 
A  Multigravida  at  the  Thirty-fourth 
Week.  Who  Died  before  Any  Labor  Pains 
Occurred.  Note  the  length  of  the  cervical 
canal  and  the  closed  condition  of  the  internal 
OS. — {Leopold.) 


314  PATHOLOGICAL  PREGNANCY. 

has  a  decided  constricting  influence  upon  the  body  of  the  uterus  and  the  cervix, 
which  is  most  defi^iitely  exemplified  at  the  internal  os.  Consequently,  there  will 
be  imminent  danger  of  uterine  rupture  in  any  method  of  rapid  manual  dilata- 
tion of  the  OS  undertaken  before  the  internal  os  has  at  least  partly  disappeared. 
This  fact  particularly  concerns  primiparse,  in  whom  the  supravaginal  portion  of 
the  cervix  persists  late  in  pregnancy,  and  even  up  to  the  beginning  of  labor. 
Uterine  rupture  and  death  have  not  infrequently  followed  the  careless  perform- 
ance of  rapid  manual  dilatation  of  the  os,  especially  in  eclampsia;  and  undue 
shock  has  been  caused  by  dragging  a  fetus  through  an  imperfectly  dilated  os, 
not  to  speak  of  the  death  of  the  child.  Hence  the  greatest  care  in  this  manipula- 
tion is  demanded.  In  case  of  placenta  praevia,  the  lower  uterine  segment  and 
the  cervix  are  made  more  easily  dilatable  by  the  hemorrhage  and  supervening 
anemia.  The  reverse  is  true  in  eclampsia,  as  has  been  before  suggested.  Great 
care  should  be  taken  not  to  extract  the  fetus  prematurely,  before  full  dilatation 
has  been  attained  and  the  external  os  paralyzed.  I  have  seen  cases  of  premature 
extraction,  under  these  circumstances,  which  have  been  followed  by  many  unnec- 
essary and  dangerous  lacerations  of  the  lower  uterine  segment,  and  by  an  in- 
creased mortality  of  both  mother  and  child. 

Although  I  have  the  strongest  faith  in  the  efficiency  of  an  immediate  removal 
of  fetal  metabolism  and  irritation,  in  order  not  only  to  control  but  to  cure  the 
eclamptic  attack,  I  must  protest,  first,  against  the  careless  use  of  the  term  accouche- 
ment force  as  applied  to  the  rapid,  scientific,  and  intelligent  evacuation  of  the 
uterus;  and,  secondly,  against  the  thoughtless  recommendation  of  this  method 
as  being  the  best,  if  not  the  only  one  at  our  command,  for  controUing 
eclamptic  convulsions,  without  giving  due  consideration  to  the  condition  of 
the  cervical  barrier. 

Accouchement  force  comprises  to-day  three  operations — namely,  (i)  the  com- 
plete instrumental  or  manual  dilatation  of  the  cervical  canal,  followed  by  (2) 
either  combined  or  direct  version,  or  the  application  of  the  forceps,  and  (3)  the 
immediate  extraction  of  the  child.  It  is  well  for  the  patient  suffering  from  an 
eclamptic  seizure  that  the  frequency  of  the  convulsions  increases  proportionately 
with  the  progress  of  pregnancy.  As  already  stated,  it  is  unfortunate  that  the 
eclamptic  seizure  is  four  times  more  frequent  in  primiparae  than  in  multiparse,  and 
in  primiparse  the  persistence  of  the  supravaginal  part  of  the  cervix,  even  to  late 
gestation,  and  of  a  rigid  and  unrelaxing  os,  necessitates  the  use  of  preliminary  and 
temporizing  methods  before  a  rapid  dilatation  of  the  os  and  subsequent  extraction 
of  the  fetus  can  be  safely  performed.  In  these  cases  which  are  so  critical,  after 
the  institution  of  measures  preparatory  to  a  rapid  dilatation  and  evacuation  of 
the  uterus  and  waiting  for  them  to  culminate,  so  that  at  least  the  cervical  canal 
may  have  been  rendered  somewhat  relaxed,  even  if  the  internal  os  has  not 
partly  disappeared,  my  experience  has  proved  veratrum  viride  invaluable,  for 
the  preservation  of  life,  on  account  of  the  various  characteristics  of  the  drug, 
before  described.  Vaginal  Csesarean  section  should  also  be  considered  in  such 
cases  as  a  substitute  for  mechanical  dilatation. 


DISEASES  OF  THE    URINARY   TRACT.  315 


XI.  DISEASES  OF  THE  URINARY  TRACT. 

/.  Passive  Congestion  of  the  Kidney.  2.  Acute  Nephritis,  j.  Chronic  Nephritis.  4.  Floating 
Kidney,  Tumors  of  the  Kidney.  5.  Pyelonephritis.  6.  Hydronephrosis.  7  Renal 
Calculi.  8.  Renal  Insufficiency,  and  Toxemia,  g.  Vesical  Irritation.  10.  Cystitis. 
II.  Incontinence  of  Urine.  12.  Urinary  Retention,  ij.  Vesical  Hemorrhoids.  14.  Vesi- 
cal Calculi.  75.  Cystocele.  16.  Vesical  Neoplasms  and  Traumatism.  ly .  Albumin- 
uria. 18.  Polyuria,  ig.  Peptonuria.  20.  Hematuria.  21.  Glycosuria.  22.  Lipuria 
and  Chyluria.     23.  Acetonuria.     24.    Urinary  Sediments  of  Pregnancy. 

1.  Passive  Congestion  of  the  Kidney. — This  condition,  when  due  to  any 
obstruction  of  the  return  flow  of  venous  blood,  may,  of  course,  complicate 
pregnancy;  but  the  term  is  usually  applied  to  a  supposed  consequence  of  the 
pressure  of  the  gravid  uterus  itself.  Anemia  of  the  kidney:  But  since  the  in- 
creased intra-abdominal  pressure  of  pregnancy  aifects  the  renal  arteries  as  well 
as  the  veins,  the  tendency  is  naturally  toward  an  anemic  rather  than  a  passively 
congested  kidney.  This  anemia  is  assumed  to  be  the  forerunner  of  albuminuria 
and  fatty  degeneration;  or,  in  other  words,  is  the  first  step  in  the  formation 
of  the  so-called  kidney  of  pregnancy.  Its  existence  is  naturally  associated  with 
the  latter  part  of  pregnancy,  after  the  gravid  uterus  has  attained  a  certain 
size;  but  some  see  in  anemia  of  the  kidney  a  reflex  element,  believing  that 
compression  of  the  nerves  in  the  uterus  causes  a  lowering  of  blood-pressure  in 
the  kidney.  Pregnancy-kidney:  This  important  condition  is  considered  under 
toxemia  of  pregnancy,  eclampsia,  and  albuminuria.  It  is  enough  to  state  here 
that  it  is  essentially  a  fatty  degeneration  or  infiltration  of  the  renal  epithelia 
which  varies  much  in  degree,  but  which  with  very  few  exceptions  undergoes 
complete  resolution  after  delivery.  There  is  more  or  less  tendency  toward 
recurrence  at  subsequent  pregnancies. 

2.  Acute  Nephritis. — Acute  nephritis  may  develop  during  pregnancy  as  a 
purely  accidental  complication,  differing  in  nowise  as  to  etiology,  symptoms, 
etc.,  from  the  same  affection  as  it  occurs  in  the  non-gravid.  The  fact  that  such 
a  condition  is  to  be  construed  for  practical  purposes  as  a  severe  form  of  preg- 
nancy-kidney— with  which,  however,  it  has  no  known  relationship — makes  it 
necessary  to  state  but  little  under  a  separate  heading.  Acute  nephritis  is 
attended  with  greater  local  and  general  disturbance,  and  its  prognosis  as  a  dis- 
ease per  se  is  less  favorable.  It  tends  to  cause  uremia,  while  in  pregnancy- 
kidney  the  toxic  state  is  believed  to  precede  the  renal  lesion.  In  cases  in  which 
a  differential  diagnosis  cannot  be  made  between  acute  intercurrent  nephritis  and 
pregnancy-kidney,  it  will  be  difficult  to  decide  whether  the  toxic  state  is  uremic 
or  eclamptic.  Recent  studies  in  cryoscopy  show  a  difference  in  the  blood  in 
these  conditions;  so  that  the  differentiation  should  be  rendered  absolute. 
Finally,  acute  nephritis,  although  it  might  possibly  end  in  resolution  in  time, 
would  have  no  necessary  tendency  to  terminate  with  delivery,  and  would  in 
most  cases  result  in  chronic  nephritis,  a  termination  unusual — and  according 
to  some,  unknown — in  pregnancy-kidney. 

3.  Chronic  Nephritis. — Chronic  nephritis  sometimes  becomes  apparent  after 
conception  in  the  absence  of  any  previous  suspicion  of  the  disease.  If  a  woman 
show  the  evidences  of  renal  lesion  very  soon  after  impregnation,  the  inference  is 
that  the  affection  is  of  considerable  duration.  It  happens  occasionally  that  a 
woman  with  chronic  nephritis  becomes  pregnant  when  fully  aware  of  her  condi- 
tion. The  influence  of  gravidity  is  usually  serious,  and  becomes  more  marked  for 
each  successive  pregnancy.  The  mother  may  be  variously  affected.  She  may 
die  as  the  result  of  labor  if  the  latter  is  severe  in  character  or  complicated  by 


316  PATHOLOGICAL  PREGNANCY. 

operative  intervention.  Or  the  confinement  may  be  uneventful,  but  the  disease 
may  undergo  a  severe,  perhaps  fatal,  exacerbation  during  the  puerperium.  It 
is  known  that  these  patients  readily  become  septic,  and  that  very  slight  trauma- 
tisms may  become  infected.  While  opinion  is  divided  as  to  the  advisability  of 
interrupting  pregnancy  in  pregnancy-kidney  and  in  acute  nephritis,  authors  agree 
that  intervention  of  this  sort  is  more  justifiable  in  chronic  nephritis.  The  remark- 
able infrequency  of  eclampsia  in  chronic  nephritis  of  pregnancy  is  an  argument  in 
favor  of  the  distinction  between  uremia  and  the  toxemia  of  pregnancy. 

4.  Floating  Kidney  ;  Tumors  of  the  Kidney. — These  conditions  very  seldom 
complicate  pregnancy  and  labor.  The  pressure  of  the  gravid  uterus,  as  a  rule, 
suffices  to  keep  a  floating  kidney  in  place  for  the  time  being,  and  the  chief  danger 
from  this  abnormality  is  during  and  after  the  puerperium,  when  it  may  become 
aggravated.  If  the  displacement  is  congenital,  or  if  it  occurs  suddenly  during 
labor,  the  kidney  may  enter  the  pelvis  and  become  incarcerated.  The  pedicle  of 
an  ordinary  floating  kidney  may  become  twisted. 

5.  Pyelonephritis. — This  condition  was  formerly  unrecognized,  having  been 
confounded  with  cystitis.  In  1889  Kruse  *  first  called  the  attention  of  ob- 
stetricians to  this  complication,  and  in  1892  Reblaud  published  a  monographic 
study  of  the  subject.  Frequency:  Pyelonephritis  of  pregnancy  is  far  from  rare. 
According  to  Vinay,  at  least  one  case  occurs  annually,  on  an  average,  in  the 
Hotel-Dieu  Maternity,  Paris.  Etiology:  This  is  entirely  obscure.  Compression 
of  the  ureters,  especially  the  right,  by  the  gravid  uterus  will  not  accoimt  for  the 
lesion.  Vinay  f  and  Reblaud  both  accuse  Bacillus  coli  of  active  responsibility,  the 
latter  even  holding  that  it  gains  access  to  the  urinary  tract  by  direct  propagation 
through  the  intestine.  In  support  of  this  contention  Bue  claims  that  purgation 
aborts  pyelonephritis.  Symptoms :  The  disease  may  make  its  appearance  at  any 
period  after  the  fourth  month.  The  symptoms,  while  obscure,  are  usually  those 
which  characterize  a  severe  acute  disease,  including  a  chill,  high  temperature, 
malaise,  etc.  Pyuria  is  present,  associated  with  albuminuria.  Diagnosis:  This 
is  made  by  exclusion  of  cystitis.  There  is  induced  tenderness  over  the  kidneys. 
Prognosis:  The  disease  persists  until  pregnancy  is  terminated.  It  may  recur 
with  successive  pregnancies.  Statistics  are  rare.  Treatment:  The  indications 
are  rest  in  bed;  sedation  (hypodermatics  of  morphin),  milk  diet  and  intestinal 
antisepsis.  Vinay  recommends  benzo-naphthol  for  this  purpose.  The  disease 
does  not  appear  to  be  severe  enough  to  reqmre  the  induction  of  abortion. 

Pyelitis  is  very  rare  during  pregnancy,  being  far  more  common  in  the  puer- 
perium.    (See  Part  VII.) 

6.  Hydronephrosis. — This  affection  may  occur  as  a  result  of  pressure  on  the 
ureters  by  a  uterus  bound  down  by  adhesions  or  by  twisting  of  the  pedicle  of  a 
dislocated  kidney.  The  uterus  or  kidney  should  be  replaced  and  held  in  position 
if  possible.     Interruption  of  pregnancy  usually  occurs. 

7.  Renal  Calculi. — Renal  colic  is  rare  in  pregnant  women  because  of  its  in- 
frequent occurrence  in  the  female  sex  in  general.  The  few  published  cases  are 
probably  simply  coincidences  and  the  sole  interest  in  considering  the  subject  in 
this  connection  is  the  simulation  of  labor  pains  by  the  colic.  The  treatment  of 
the  affection  differs  in  nowise  from  that  in  the  non-pregnant. 

8.  Renal  Insufficiency. — See  Toxemia  of  Pregnancy. 

9.  Vesical  Irritation. — This  must  not  be  confounded  with  cystitis,  incon- 
tinence, or  retention,  although  some  of  these  conditions  may  occur  side  by  side. 
It  may  be  described  as  an  almost  physiological  reaction  on  the  part  of  the 
bladder  toward  the  irritation  of  the  pregnant  uterus.     The  organ  is  compressed 

*  Inaug   Dissert.,  Wurzburg.  t  "  L'0bst6trique,"  May  15,  iSqq. 


DISEASES  OF  THE   URINARY   TRACT.  317 

between  the  symphysis  in  front  and  the  gravid  uterus  behind.  It  is  an  affection 
most  complained  of  in  the  fiarly  months  of  pregnancy  and  in  primigra vidae ,  and 
tends  to  disappear  about  the  fourth  month  of  pregnancy,  but  often  returns  in  the 
last  fortnight. 

Symptoms. — The  affection  is  a  dysuria.  There  is  a  frequent  desire  to 
urinate,  with  pain  and  scalding.  The  symptoms  resemble  those  of  cystitis  but 
are  less  severe.  The  distress  is  removed  if  the  patient  takes  the  recumbent  pos- 
ture for  the  time  being.  The  bladder  is  usually  hypersensitive.  In  case  of 
malposition  of  the  uterus  the  pressure  is  usually  directed  against  the  neck  of  the 
bladder,  and  vesical  tenesmus  results.  If  the  vesical  neck  be  forced  against  the 
upper  border  of  the  symphysis  pubis,  there  may  be  retention  of  urine  (page  318). 
This  may  cause  incontinence  or  the  urine  may  be  completely  retained  and  the 
bladder  will  be  overdistended.  In  this  condition,  if  labor  supervenes,  rupture  of 
the  bladder  may  take  place,  on  account  of  the  decrease  of  abdominal  space 
caused  by  the  retraction  of  the  walls.  Cystitis  commonly  follows  overdistention. 
Abnormal  presentations  and  positions  of  the  fetus  cause  irritability  of  the 
bladder  in  the  latter  months  of  pregnancy.  There  is  either  extreme  pressure  on 
the  bladder  or  this  organ  is  pushed  out  of  place.  The  fetus  should  be  replaced 
in  normal  position,  which  can  be  accomplished  only  by  external  manipulation. 

Treatment. — The  measures  for  relief  are  those  employed  in  vesical  irritation 
in  the  non-pregnant,  or  as  in  cystitis,  to  be  mentioned  later  (rest,  dorsal  decu- 
bitus, baths,  anodynes,  etc.).  Catheterization  should  be  avoided  unless  abso- 
lutely demanded.  A  normal  presentation  of  the  fetus  should  be  secured  if 
possible  by  external  manipulation,  and  an  abdominal  binder  (Figs.  228  and 
229)  used,  which  will  relieve  the  bladder  of  fetal  pressure.  I  have  iound  the 
modified  knee-chest  posture  (Part  X),  used  twice  daily,  of  great  benefit  in 
obtaining  relief. 

ID.  Cystitis. — C\'stitis  of  pregnancy  is  not  a  rare  disease. 

Etiology. — It  may  originate  from  some  of  the  minor  urinary  troubles  develop- 
ing early  in  pregnancy,  such  as  retention  due  to  retroversion.  The  actual  deter- 
mining cause  is  bacterial,  and  a  number  of  germs  are  known  to  give  rise  to  the 
disease,  including  Bacillus  coli  and  Staphylococcus  pyogenes.  These  germs  appear 
to  be  unable  to  infect  the  normal  bladder.  Gonococcus  cystitis  is  rarely  seen  in 
pregnancy.  Cystitis  arises  either  through  importation  of  germs  by  the  catheter 
or  by  their  spontaneous  migration  from  the  vestibule  along  the  urethra. 

Symptoms. — These  consist  chiefly  in  increased  frequency  of  micturition  and 
more  or  less  scalding  with  tenesmus  at  the  close  of  the  act,  at  which  time  a  blood- 
clot  may  be  expelled.  Such  a  urine,  upon  standing,  deposits  a  heavy  sediment  con- 
sisting of  pus-corpuscles.  The  type  of  cystitis  which  follows  upon  the  irritable 
bladder  of  early  pregnancy  is  always  mild;  it  may  be  readily  overlooked  and 
mistaken  for  simple  urinary  irritation  unless  the  urine  is  carefully  tested.  On 
the  other  hand,  the  cystitis  of  retention  is  severe  and  aggravates  the  already 
existing  state  of  affairs.  The  retained  urine  may  readily  decompose,  the  pus 
being  transformed  thereby  into  a  ropy  mass.  The  combination  of  retention 
with  cystitis  has  been  known  to  produce  abortion.  The  disease  tends  to  improve 
after  delivery,  but  sometimes  persists.  In  some  women  cystitis  tends  to  recur 
with  each  pregnancy. 

Treatment. — Rest  and  avoidance  of  exposure  are  the  first  considerations. 
Hence,  in  winter  patients  had  better  be  confined  to  bed.  The  diet  should  be 
extremely  simple,  consisting  chiefly  of  clear  soups,  green  vegetables,  and  farina- 
ceous articles.  Alkaline  mineral  waters  should  be  taken  freely.  Any  diuretic 
infusion  may  be  prescribed,  with  the  additions  of  sandal-wood  in  capsules  or 


318  PATHOLOGICAL  PREGNANCY, 

salol.     Poultices  should  be  placed  over  the  hypogastrium  and  anodyne  supposi- 
tories may  be  necessary  in  severe  cases.     Urotropin  is  also  of  value. 

11.  Incontinence  of  Urine. — True  incontinence  is  rare  in  pregnancy,  although 
it  is  by  no  means  unknown  in  the  later  months.  It  should  not  be  confounded 
with  the  ordinary  vesical  irritability,  which  is  almost  inevitable,  nor  with  the 
dribbling  which  accompanies  retention.  The  principal  cause  is  the  encroachment 
on  the  bladder  of  the  more  dependent  portions  of  the  fetus  during  the  last  weeks 
of  pregnancy.  If  the  fetus  press  fairly  upon  it,  any  sudden  movement  of  the 
diaphragm,  as  in  laughing,  coughing,  etc.,  could  readily  cause  the  emptying  of 
the  viscus.  The  constant  escape  of  urine  may  give  rise  to  excoriations  of  the 
vulva  and  thighs.  An  abdominal  bandage  will  usually  relieve  this  condition 
(Figs.  228  and  229). 

12.  Urinary  Retention. — This  is  conceded  to  be  the  most  prevalent  of  all  the 
urinary  anomaUes  of  pregnancy,  owing,  perhaps,  to  the  number  of  types  which 
the  condition  assumes.  These  are  as  follows:  (i)  Retention  at  the  onset  of  preg- 
nancy. The  rationale  of  this  is  obscure.  This  is  attributed  to  reflex  spasm  of 
the  vesical  neck.  (2)  Retention  in  the  course  of  pregnancy.  This  is  due  almost 
exclusively  to  retroversion  of  the  pregnant  uterus,  and  begins  at  the  third  or 
fourth  month.  (3)  Retention  toward  the  close  of  pregnancy.  This  is  the  result 
of  the  direct  compression  of  the  urethra  and  bladder  by  the  fetal  head. 

Symptoms. — These  are  self-evident — the  urinary  tumor  and  the  failure  to 
pass  water  beyond  a  mere,  dribbling.  This  dribbling  saves  the  patient  in  most 
cases  from  the  accidents  of  complete  retention.  If  dribbling  does  not  occur 
spontaneously,  the  patient  is  still  able  to  get  relief  by  efforts  at  bearing-do#n. 
There  is  naturally  much  dysuria  and  reflected  pain,  while  in  some  instances  there 
is  a  systemic  reaction,  including  fever,  anxiety,  restlessness,  and  anasarca.  If  the 
case  is  left  to  itself  the  bladder  gradually  distends  until  it  assumes  a  prodigious 
volume.  The  use  of  the  catheter  is  quite  likely  to  lead  to  infection  and  cystitis. 
The  diagnosis  is  readily  established  by  palpation  and  the  catheter.  The  drib- 
bling of  retention  .should  not  be  confounded  with  true  incontinence.  The 
prognosis  depends  upon  the  character  of  the  relief  afforded  by  the  use  of  the 
catheter  and  by  attempts  to  remove  the  cause.  Treatment:  The  prompt  and 
repeated  use  of  the  catheter  will  insure  the  patient  against  the  immediate  un- 
favorable results  of  retention.  This  is  offset  somewhat  by  the  dangers  of 
catheterization.  It  may  be  necessary  to  introduce  the  instrument  in  the  genu- 
pectoral  position.     Glass  is  the  best  material  for  the  catheter  (Part  X). 

13.  Vesical  Hemorrhoids. — These,  like  other  local  pelvic  varicosities  occur- 
ring during  pregnancy,  are  the  result  of  the  general  pelvic  congestion,  and 
usually  first  draw  attention  to  the  condition  on  the  occurrence  of  rupture  and 
consequent  hematuria.  The  condition  can  only  be  suspected  until  cystoscopic 
examination  be  made. 

14.  Vesical  Calculi. — Vesical  calculi  have  caused  vesico-vaginal  fistula  dur- 
ing labor  and  a  case  is  recorded  in  which  a  stone  was  found  large  enough  to 
obstruct  delivery.*  The  induction  of  labor  during  the  last  month  of  pregnancy 
may  be  demanded;  this  late  date  being  chosen  in  order  that  the  prognosis  for 
the  child  may  be  rendered  as  favorable  as  possible. 

15.  Cystocele. — This  may  cause  a  pouching  of  the  anterior  vaginal  wall,  the 
tumor  even  passing  through  the  vulva.  It  has  been  mistaken  for  the  amniotic 
sac  and  punctured.  For  diagnosis  a  catheter  may  be  passed  into  the  cystocele 
and  palpated  by  vaginal  touch.  For  treatment,  after  the  bladder  is  evacuated, 
the  anterior  vaginal  wall  should  be  pushed  up  in  order  that  pressure  by  the  head 
may  be  avoided. 

*  Dakin:  "Handbook  of  Midwifery,"  page  460. 


DISEASES  OF  THE    URINARY   TRACT.  319 

1 6.  Vesical  Neoplasms  and  Traumatisms. — Carcinoma  may  occur  and  be 
secondary  to  carcinoma  of  the  cervix.  Vesical  irritation  and  hematuria  are 
among  the  symptoms. 

17.  Albuminuria. — The  subject  of  albuminuria  in  the  gravid  is  an  extensive 
one,  which  is  considered  under  toxemia  of  pregnancy,  eclampsia,  etc.  It 
merits  some  independent  consideration  as  well.  Occurring  in  the  first  half  of 
pregnancy  it  must  be  regarded  as  of  toxic  origin,  or  as  suggestive  of  hepatic 
insufficiency  or  renal  disease.  The  so-called  functional  albuminuria — which 
is  now  believed  to  depend  largely  upon  gastric  insufficiency — may  be  present 
before  conception;  but  von  Rosthom  (Winckel's  "Handbuch,"  1903)  assures 
us  that  this  condition  never  becomes  aggravated  by  pregnancy,  and  that  it  is 
not  necessary  to  dissuade  women  with  this  anomaly  from  marriage  and  con- 
ception. 

True  albuminuria  of  pregnancy  begins,  as  a  rule,  not  earlier  than  the 
twenty- fifth  week;  and  it  is  of  such  common  occurrence  that  some  regard 
it  as  practically  the  rule.  Once  believed  to  be  much  more  common  in  primi- 
gravidas,  it  is  now  thought  to,  occur  irrespective  of  parity.  It  is  probable  that 
a  small  amount  of  albumin  in  the  urine  may  be  accounted  for  by  circulatory 
disturbances  alone,  and  that  to  be  considered  evidence  of  a  toxic  state,  album- 
inuria must  be  associated  with  other  phenomena.  When  the  amount  is  con- 
siderable, or  when  it  steadily  increases  from  small  beginnings,  it  naturally  sug- 
gests both  a  toxic  state  and  a  renal  lesion.  It  by  no  means  follows  that  the  trace 
of  albumin  so  often  found  comes  directly  from  the  blood,  for  it  may  simply  be 
derived  from  the  epithelia  and  leucocytes  which  make  their  appearance  in  the 
urine  in  increasing  numbers  late  in  pregnancy.  Naturally  only  traces  could  be 
accounted  for  in  this  manner. 

The  fact  should  be  emphasized  that  waste  of  albumin  is  not  without  signi- 
ficance in  pregnancy.  Albuminuric  women  show  a  distinct  tendency  to  abortion 
and  premature  delivery ;  and  while  the  fetus  shows  subdevelopment  the  placenta 
is  increased  in  size  and  shows  such  peculiarities  as  to  be  termed  the  "  albuminuric 
placenta."  This  subject  needs  to  be  studied  anew,  for  it  is  possible  that  a 
certain  phase  of  endometritis  gravidarum  may  account  for  the  entire  condition. 

18.  Polyuria. — Owing  to  increased  tissue  change,  a  moderate  increase  of  the 
urinary  secretion  always  occurs  during  pregnancy.  Occasionally  the  increase 
is  excessive.  Cases  are  recorded  in  which  200  or  more  ounces  (6  liters)  in  a 
day  were  passed.  The  urine  is  usually  normal  in  character  except  for  a  low 
specific  gravity.  The  patient  suffers  from  thirst  and  the  annoyance  caused  by 
frequent  urination.  Treatment  adapted  to  cause  decrease  in  the  flow  of  urine  is 
not  advisable. 

19.  Peptonuria. — This  is  sometimes  caused  by  fetal  death  and  the  absorption 
of  proteids  (page  272).     In  other  cases  no  assignable  cause  can  be  found. 

20.  Hematuria. — This  is  usually  due  to  vesical  hemorrhoids,  but  may  occur 
from  other  affections  of  the  bladder  and  kidneys,  as  acute  nephritis  or  cystitis, 
calculi,  neoplasms,  or  traumatisms  of  the  bladder.  For  treatment  the  pelvic 
congestion  should  be  relieved  by  avoiding  constipation  and  tight  clothing.  In- 
jections of  astringent  solutions  may  be  tried  in  bad  cases  if  the  symptoms  point 
to  the  bladder  as  the  seat  of  the  trouble. 

21.  Glycosuria. — The  existence  of  glycosuria  in  pregnancy  and  the  puer- 
perium  has  been  known  for  many  years,  and  in  1877  it  was  ascertained  that 
puerperal  glycosuria  was  a  lactosuria,  and  thereby  related  in  some  manner  to 
the  secretion  of  milk.  The  glucose  which  may  sometimes  appear  to  indicate  a 
toxemia  should  not  be  regarded  as  necessarily  pathological,  for  if  the  tests  are 


320  PATHOLOGICAL  PREGNANCY. 

of  sufficient  delicacy  this  substance  may  be  found  in  nearly  all  urine,  and 
must,  under  these  circumstances,  be  regarded  as  purely  dietetic.  This  fact 
was  made  the  basis  of  Schenck's  method  of  controlling  sex  of  the  offspring; 
since  if  the  normal  trace  of  sugar  cannot  be  made  to  disappear  by  diet,  the 
infant  will  probably  be  a  female.  Regarding  the  high  degrees  of  glycosuria 
and  true  diabetes,  since  these  conditions  may  develop  during  pregnancy  or 
be  present  throughout  it,  the  outlook  is  much  the  same  as  in  operative 
surgery,  and  the  greater  the  degree  of  glycosuria,  the  worse  the  prognosis. 
Statistics  appear  to  show  that  labors  in  these  women  are  quite  apt  to  end  unfavor- 
ably in  one  or  another  way.*  The  fact  that  diabetes  has  been  known  to  set  in 
during  pregnancy  and  disappear  spontaneously  after  delivery  would  seem  to 
connect  such  a  phenomenon  with  the  special  toxemia  of  pregnancy.  Women 
who  have  thus  recovered  have  gone  through  subsequent  pregnancies  without 
reappearance  of  the  disease.  Other  records  indicate  that  a  diabetes  lighted  up 
in  pregnancy  may  remain  permanent.  When  a  diabetic  woman  becomes 
pregnant,  her  disease  usually  takes  a  turn  for  the  worse,  with  a  tendency  to 
improve  temporarily  after  confinement.  According  to  Lecorche,  true  diabetics 
who  become  pregnant  usually  succumb  to  the  disease  within  a  short  time  after 
delivery. 

22.  Lipuria  and  Chyluria. — These  conditions  are  occasionally  noticed.  The 
former  is  due  to  the  general  increase  in  adipose  tissue  throughout  the  body. 
They  are  of  no  special  clinical  importance. 

23.  Acetonuria. — The  metabolic  changes  incident  to  pregnancy  would 
naturally  direct  one's  attention  to  the  index  of  metabolism,  the  urine.  The 
significance  of  acetonuria  in  general  not  being  well  understood,  such  an  investi- 
gation as  that  undertaken  by  Max  Stoltz.t  in  "Acetonuria  in  Pregnancy,  Child- 
birth, and  Puerperium,"  is  highly  welcome.  He  finds  that  a  slight  acetonuria 
which  is  physiologically  found  in  pregnant  women  is  not  constant  but  is  quite 
variable.  Increased  acetonuria  is  frequently  found  in '  the  course  of  preg- 
nancy, lasting  for  one,  two,  or  three  days,  without  any  symptoms  of  patho- 
logical causes.  In  the  majority  of  cases  during  child-birth  there  is  increased 
acetonuria.  The  longer  the  labor  lasts,  the  more  frequently  does  acetonuria 
occur  and  the  more  abundant  it  is.  In  primiparae  it  is  more  constant  and  greater 
than  in  multiparae.  During  the  first  thiree  days  of  the  puerperium,  occasionally 
during  the  first  four  days,  it  is  considerably  increased.  Less  often  it  appears 
greatly  increased  later  in  the  puerperium.  The  increased  acetonuria  of  the  puer- 
perium is,  as  a  rule,  closely  connected  with  the  same  condition  during  parturi- 
tion. The  influence  of  the  establishment  and  the  continuance  of  lactation  upon 
this  condition  requires  further  investigation.  Increased  acetonuria  in  pregnancy 
and  parturition  is  worthless  as  an  index  of  the  death  of  the  fetus.  It  is  a  phy- 
siological manifestation,  without  any  pathological  significance  or  cause.  It 
is  explained  by  the  alteration  in  fat  metabolism  during  pregnancy  and  the  suc- 
ceeding states,  and,  corresponding  to  it,  is  of  irregular  and  transitory  duration. 

24.  Urinary  Sediments  of  Pregnancy. — It  is  now  known  that  abnormal 
deposits  occur  in  the  urine  of  the  gravida  in  the  latter  half  of  pregnancy  in  not 
less  than  97  per  cent,  of  all  cases.  (Fischer,  "Arch.  f.  Gynekol.,"  xliv.)  This 
appears  to  result  largely  from  circulatory .  disturbances  which  are  inseparable 
from  direct  and  indirect  pressure  from  the  enlarging  uterus.  There  is  more 
or  less  desquamation  along  the  entire  urinary  tract,  as  shown  by  catherisation 
of  the  ureters.     In  the  renal  epithelia  fat  droplets  may  sometimes  be   seen. 

*  Matthews  Duncan:  "Trans.  Obstet.  Soc.  London,"  1882. 
t  "Archiv  f.  Gyn.,"  Feb.,  1902. 


DISEASES  OF  THE  ALIMENTARY   TRACT.  321 

There  is  always  a  leucocytosis  in  the  urine  of  the  gravid,  and  the  corpuscles 
may  proceed  from  the  bladder  or  kidney;  in  the  latter  case  being  accompanied 
by  albuminuria.  Erythrocytes  and  hematoidin  crystals  are  sometimes  encoun- 
tered; and  are  thought  to  proceed  almost  wholly  from  the  ureters  unless,  of 
course,  nephritis  is  present.  Finally  it  is  not  uncommon  to  find  hyaline  casts 
(25  per  cent.,  Fischer),  which  are  by  no  means  necessarily  associated  with  al- 
buminuria. These  cylinders  are  sometimes  covered  in  part  by  renal  epithelial 
leucocytes,  or  erythrocytes.  Granular  casts  are  present  but  rarely  and  are 
always  accompanied  by  albuminuria. 

These  sediments  are  present  at  first  but  sparsely,  but  increase- regularly 
toward  term.  During  labor  they  attain  a  maximum,  and  erythrocytes  are 
then  invariably  present  in  large  numbers. 


XII.  DISEASES  OF  THE  ALIMENTARY  TRACT. 

I.  Gingivitis.  2.  Dental  Caries,  j.  Oral  Sepsis.  4.  Salivation  or  Ptyalism.  5.  Anorexia. 
6.  Nausea  and  Vomiting  7.  Persistent  Vomiting;  Hyperemesis  Gravidarum.  8.  Mal- 
acia;  Longings.  g.  Gastric  and  Intestinal  Indigestion.  10.  Consumption.  11.  Diar- 
rhea. 12.  Hemorrhoids,  ij.  Jaundice;  Icterus  Gravidarum.  14.  Appendicitis.  75. 
Tapeworm. 

1.  Gingivitis. — An  inflammation  of  the  gums  due  to  the  blood-changes  of 
pregnancy  not  infrequently  occurs  during  gestation.  It  usually  subsides  after  the 
birth  of  the  child,  though  it  may  continue  throughout  lactation.  This  affec- 
tion is  generally  coincident  with  salivation,  although  it  may  occur  alone, 
and  is  more  frequently  seen  in  multigravidas  than  in  primigravidae.  The  gums 
are  swollen  and  tender  and  bleed  at  the  slightest  touch;  they  are  retracted, 
leaving  the  necks  of  the  teeth  exposed  to  all  the  secretions  of  the  mouth,  and  as 
these  are  frequently  very  acid,  their  effect  upon  the  teeth  is  deleterious.  The 
latter  are  apt  to  become  loosened,  making  mastication  difficult  as  well  as  painful; 
the  rest  of  the  mouth  may  be  involved  and  the  process  extend  to  the  pharynx 
and  even  to  the  stomach;  the  breath  has  an  unpleasant  odor.  Treatment:  The 
teeth  should  receive  the  careful  attention  of  a  dentist.  A  good  remedy  is  pre- 
cipitated chalk  pressed  between  the  teeth  at  bedtime.  During  the  day  milk  of 
magnesia  may  be  used  repeatedly  as  a  mouth-wash. 

2.  Dental  Caries. — The  rapid  decay  of  the  teeth  seen  in  many  women  during 
pregnancy  is  not  due  to  the  deficiency  of  lime  salts  in  the  blood,  as  it  has  never 
been  shown  that  there  is  such  a  deficiency;  but  it. is  undoubtedly  caused  by  the 
acid  eructations,  vomiting,  and  secretions,  the  result  of  acid  dyspepsia  of  the 
early  months  of  gestation.  I  have  frequently  noted  in  my  private  practice  that 
the  number  of  teeth  attacked  and  the  rapidity  of  dental  caries  were  directly  pro- 
portionate to  the  frequency,  intensity,  and  persistency  of  acid  dyspepsia  with 
eructations  and  vomiting.  Biro  *  has  shown  that  mere  pregnancy,  aside  from 
causing  acid  dyspepsia,  has  no  effect  on  the  teeth.  One  of  the  first  duties  of 
the  obstetrician  toward  his  patient  in  pregnancy  is  to  inquire  into  the  condition 
of  the  teeth  and  mouth,  and,  if  necessary,  to  send  the  patient  to  her  dentist. 
Dental  caries  lapping  over  into  or  originating  during  pregnancy  should  receive 
immediate  attention.  The  carious  substance  should  be  partly  or  completely  re- 
moved, the  cavity  touched  with  pure  carbolic  acid  (an  alkali),  and  a  temporary 
gutta-percha  filling  put  in.  Severe  and  painful  dental  procedures,  however,  with- 
out the  use  of  cocain  or  nitrous  oxide,  should  be  avoided,  since  they  may  lead 

*  "  Wien.  med.  Blatter."  1S98. 
21 


322  PATHOLOGICAL   PREGNANCY. 

to  abortion.  For  prevention  we  have  nothing  so  efficacious  as  the  free  use  locally 
of  alkalies,  such  as  milk  of  magnesia,  lime-water,  or  bicarbonate  of  soda,  my 
preference  being  for  the  first.  This  should  be  used  as  a  mouth-wash  after  each 
meal  and  at  bedtime,  care  being  taken  to  draw  the  fluid  between  the  teeth. 
It  may  be  used  oftener  when  the  vomiting  of  pregnancy  is  persistent.  Small 
doses  of  milk  of  magnesia  taken  internally  will  often  correct  acidity,  relieve  vom- 
iting, and  thus  prevent  dental  caries.  In  all  cases  attention  must  be  given  to 
the  dyspepsia  present. 

3.  Oral  Sepsis. — The  mouth  should  be  examined  in  all  cases  of  fever  or 
septic  symptoms  occurring  during  pregnancy  or  the  puerperium,  and  particu- 
larly in  instances  of  persistent  nausea  and  vomiting  of  pregnancy.  Many 
pregnant  women,  consciously  or  unconsciously,  have  ulceration  from  caries 
going  on  at  the  root  of  an  old  molar,  which  intermittently  discharges  a  foul  pus 
at  the  edge  of  the  gums  (pyorrhoea  alveolaris).  Again,  the  rapid  increase  in  the 
use  of  bridges  and  gold  caps  over  old  broken-down  fangs  is,  I  am  sure,  an 
important  factor  in  oral  sepsis.  Often  we  find  bone  necroses  under  these  caps 
and  bridges,  and  pus  organisms  from  this  source  are  most  virulent.  Not  only  is 
this  local  septic  condition  a  cause  of  stomatitis,  but  it  is,  the  author  feels  sure,  an 
important  and  prevalent  cause  of  gastric  disturbances  and  systemic  infection. 
In  one  of  my  cases  a  second  molar,  decaying  and  ulcerating  at  the  roots,  was 
removed  under  nitrous  oxide  by  Dr.  Hasbrouck,  of  New  York,  in  the  middle  of 
gestation;  this  was  followed  by  a  distinct  improvement  in  pronounced  gastric 
disturbances  present,  and  a  cessation  of  symptoms  which  resembled  an  atypical 
form  of  malarial  infection,  and  which  were  attributed  at  the  time  to  imperfect 
plumbing.  In  my  belief  these  general  phenomena  were  septic  in  character. 
Treatment:  The  source  of  the  pus  should  be  removed,  with  the  use  of  nitrous 
oxide  if  necessary;  especially  should  necrosed  and  useless  fangs  be  extracted,  and 
proper  drainage  effected.  More  attention  should  be  given  to  oral  antisepsis 
than  has  hitherto  been  the  custom;  caps  and  bridges  should  be  avoided;  all 
removable  mouth  plates  should  be  sterilized  daily;  in  cases  in  which,  for  any 
reason,  removal  of  necrosed  teeth  is  not  advisable,  or  the  patient  refuses 
to  have  it  done,  the  stump  should  be  thoroughly  touched  daily  with  carbolic 
acid  (i  :  20),  and  several  times  a  day  an  antiseptic  mouth- wash,  such  as  per- 
oxide of  hydrogen  (i  14),  should  be  used. 

4.  Salivation  or  Ptyalism. — This  occurs  most  commonly  in  the  early  months  of 
pregnancy,  and  consists  in  a  profuse  secretion  of  saliva;  the  patient  suffers  from  a 
continual  dribbling  which  is  very  annoying;  the  condition  is  due  to  a  neurosis  or 
toxemia.  Sometimes  the  amount  of  saliva  expectorated  in  twenty-four  hours  will 
reach  two  or  more  quarts.  The  general  health  may  even  be  impaired  by  this 
trouble;  and  in  certain  instances  the  affection  continues  to  term,  and,  very  excep- 
tionally, for  some  months  after  labor.  The  danger  to  the  patient  lies  in  the 
inanition  which  results  from  this  drain  on  the  system.  In  Schramm's  case  the 
ptyalin  was  absent,  so  that  the  saliva  had  no  digestive  properties  left.  The 
mucous  membrane  of  the  mouth  becomes  red  and  swollen ;  there  is  no  fetor,  and 
this  distinguishes  the  affection  from  mercurial  ptyalism.  Treatment:  Astringent 
tablets,  such  as  troches  of  tannic  acid,  and  counterirritation  over  the  parotids  are 
useful;  the  bromides  are  most  often  of  service;  atropin  or  belladonna  may  be 
tried;  careful  attention  to  the  general  health  is  necessary. 

5.  Anorexia. — Complete  anorexia  sometimes  occurs;  more  commonly  there 
is  a  disgust  for  particular  kinds  of  food,  rather  than  absolute  anorexia.  This 
condition  is  apt  to  mianifest  itself  at  either  extreme  of  pregnancy,  when  the 
neurotic  features  are  most  predominant.     Sometimes  the  patient  will  not  be  able 


•    DISEASES  OF  THE   ALIMENTARY   TRACT.  323 

to  bear  the  thought  of  meat  of  any  kind;  again,  she  can  take  nothing  else  but 
meat.  Treatment:  Tonics  .and  vegetable  bitters  are  useful;  the  liver  and 
bowels  should  be  carefully  regulated,  and  the  patient  should  be  humored  as 
much  as  possible  in  the  choice  of  food. 

6.  Nausea  and  Vomiting. — (See  Toxemia  of  Pregnancy,  page  291.) 

7.  Pernicious  Vomiting ;  Hyperemesis  Gravidarum. — (See  Toxemia  of  Preg- 
nancy, page  291.) 

8.  Malacia  ;  Longings. — Patients  will  occasionally  show  a  perverted  appetite 
for  unnatural  and  unheard-of  articles  of  diet.  This  affection  is  also  designated 
as  pica,  or  more  popularly  as  pining.  In  very  rare  cases  it  may  be  exaggerated 
to  true  insanity.  Gentle  treatment  may  have  some  effect ;  the  mind  should  be 
diverted;  hygiene,  particularly  of  the  alimentary  tract,  should  be  carefully 
looked  after,  and,  if  necessary,  moral  suasion  should  be  tried.  Labor  terminates 
these  symptoms. 

9.  Gastric  and  Intestinal  Indigestion. — These  affections  often  occur  in  preg- 
nancy, especially  in  primigravidse.  Pyrosis  or  heartburn  is  particularly  trouble- 
some in  the  gastric  form,  enteralgia  being  most  striking  in  the  intestinal  dis- 
turbance. These  discomforts  are  manifest  most  often  in  late  pregnancy. 
Treatment:  Attention  to  diet  and' the  relief  of  constipation  may  be  all  that  will 
be  necessary.  Alkalies  are  frequently  useful  in  pyrosis.  Pepsin,  pancreatin, 
diastase,  powdered  calumba,  the  alkaline  mineral  waters,  and  an  occasional 
dose  of  calomel  may  be  symptomatically  indicated.  In  the  intestinal 
indigestion  of  pregnancy  I  have  obtained  good  results  from  a  mixture 
of  hydrastis,  bicarbonate  of  potassium,  and  pancreatin  or  essence  of  pepsin 
(Fairchild). 

10.  Constipation. — This  is  a  common  accompaniment  of  pregnancy,  and  is 
due  partly  to  pressure,  but  mostly  to  deficient  innervation  of  the  muscular 
coat  of  the  bowel,  causing  an  exaggeration  of  the  normal  intestinal  torpidity  of 
women.  Women  sometimes  pass  a  week  or  more  without  defecation,  and 
then  copraemic  symptoms,  such  as  mental  dulness,  dizziness,  distended  veins,  and 
headache,  are  apt  to  supervene.  The  direct  mechanical  pressure  of  the  enlarging 
uterus  on  the  intestines  has  been  shown  by  frozen  sections  to  be  almost  insignifi- 
cant. However,  the  distended  anterior  abdominal  wall  is  deprived  of  much  of 
its  power  as  a  factor  in  defecation.  Constipation  has  a  tendency  to  cause 
hemorrhoids,  and  may  even,  by  accumulations  in  the  colon,  predispose  to 
abortion. 

Treatment  should  be  prophylactic,  as  far  as  possible;  the  trouble  should  be 
anticipated  early  in  pregnancy  by  a  laxative  diet,  including  fruits,  and  an 
abundant  quantity  of  plain  water,  drunk  at  bedtime  and  on  rising  in  the  morning. 
In  the  curative  treatment  violent  cathartics  must  be  avoided,  as  they  usually 
exaggerate  the  condition  subsequently,  and  have  been  known  to  interrupt 
pregnancy.  In  neglected  cases  of  several  days'  standing  repeated  enemata  of 
sweet  oil  and  ox-gall  may  be  necessary  to  unload  the  impacted  rectum,  or  even 
the  mechanical  use  of  the  spoon,  followed  by  enemata.  Ordinarily  the  best 
results  will  be  obtained  by  the  use  at  bedtime  of  pills  containing  varying  quanti- 
ties of  aloin,  cascarin  or  extract  of  cascara,  extract  of  belladonna,  strychnin, 
podophyllin,  and  capsicum.  These  pills  or  tablets  may  be  obtained  the  world 
over.  Experience  has  taught  me  that  one  formula  will  not  be  suitable  for 
all;  I  am,  therefore,  accustomed  to  use  as  many  as  six  different  combinations, 
according  to  the  nature  of  the  case.  It  will  sometimes  be  necessary  to  try  three 
or  four  different  formulas,  until  a  suitable  one  is  found.  Extract  of  cascara  sagrada, 
^  gr.  (0.03);  cascara  sagrada  cordial,  one  or  more  teaspoonfuls  (4  to  8);   fluid 


324  PATHOLOGICAL  PREGNANCY. 

extract  of  cascara,  in  increasing  doses,  after  meals  or  at  bedtime;  compound 
licorice  powder,  capsules,  tablets,  or  pills  of  inspissated  ox-gall,  2  grains  (0.12); 
extractum  pancreatis,  2  grains  (0.12);  and  extract  nux  vomica,  ^  grain  (0.015); 
after  meals  and  at  bedtime;  small  doses  of  Apenta,  Birmenstarff,  Marien- 
bad,  Hunyadi,  Friedrichshalle,  Villacabras,  or  Rubinat-Condal  waters,  an  hour 
before  breakfast,  are  all  reliable  remedies;  but  a  suitable  one  for  each  individual 
case  must  be  chosen.  For  years  I  have  been  in  the  habit  of  using  combinations 
of  these  waters,  as  Marienbad  and  Birmenstarff,  equal  parts;  Birmenstarff  half  a 
tumblerful  and  Villacabras  one  or  two  tablespoonfuls ;  Friedrichshalle  half  a  glass, 
and  one  or  two  tablespoonfuls  of  Villacabras,  or  four  tablespoonfuls  of  Rubinat 
water.  Combinations  of  Apenta  and  the  stronger  purgative  waters  can  be  made 
in  the  same  way.  I  have  found  Friedrichshalle  water,  one-third  of  a  tumblerful, 
and  Saratoga  Hawthorne  water  two-thirds,  a  pleasant  and  valuable  laxative 
and  a  marked  diuretic. 

Enemata  of  plain  soapsuds,  and  of  oil,  glycerin,  and  ox-gall,  as  well  as  laxa- 
tive suppositories  of  glycerin  and  gluten,  are  occasionally  useful,  but  should 
not  be  used  continuously  for  fear  of  irritating  the  rectum.  Various  pastes  con- 
taining figs  are  often  useful.  A  good  laxative  fig  paste  is  made  from  one  pound 
of  figs,  two  ounces  of  senna,  one  ounce  of  coriander  seed,  and  sugar  enough  to 
make  a  paste.  Small  quantities  of  this  paste  may  be  taken  at  bedtime,  or  even 
after  meals. 

11.  Diarrhea. — This  is  not  common,  but  occasionally  occurs  as  the  result  of 
irritation  from  pressure,  and  from  errors  in  diet.  If  severe,  it  may  cause  an 
interruption  of  pregnancy,  hence  it  is  more  serious  than  constipation,  and  when 
it  amounts  to  dysentery  it  is  most  unfavorable.  The  treatment  consists  in  the 
use  of  astringents,  such  as  tannin  or  aromatic  sulphuric  acid,  combinations  of 
opium,  bismuth,  chalk,  and  zinc,  and,  in  neurotic  subjects,  the  administration 
of  nerve  sedatives  and  bromides. 

12.  Hemorrhoids  are  common,  on  account  of  the  general  pelvic  congestion 
incident  to  pregnancy,  and  the  direct  effect  upon  the  circulation  of  the  uterine 
pressure.  They  are  often  due  to  constipation  and  straining.  Very  rarely  are 
the  hemorrhoids  of  pregnancy  the  cause  of  severe  hemorrhage,  anal  fissures, 
and  fistulse;  nevertheless  they  cause  intense  discomfort  and  even  suffering. 
Treatment:  Operations  are  to  be  avoided,  as  likely  to  induce  premature  labor. 
The  recumbent  position,  and  the  frequent  assumption  of  the  knee-chest  position, 
will  be  useful;  constipation  should  be  avoided;  benefit  may  be  derived  from  the 
use  of  astringent  and  anodyne  ointments  and  suppositories;  e.  g.,  unguentum 
gallae,  unguentum  stramonii,  equal  parts;  opium  suppositories;  compound  oint- 
ment of  galls.  The  application  of  fluid  extract  of  witch-hazel  upon  a  compress, 
and  this  in  turn  covered  with  an  ice-bladder,  will  often  afford  relief.  For  the 
constipation,  sulphur,  alone  or  in  combination  with  aloin  and  extract  of  bella- 
donna, is  valuable. 

13.  Jaundice  ;  Icterus  Gravidarum. — (See  Toxemia  of  Pregnancy,  page  291.) 

14.  Appendicitis. — While  this  condition  is  at  present  regarded  as  rare  in 
pregnancy,  it  is  probable  that  its  frequency  will  become  much  greater,  since 
the  disease  itself  seems  to  be  on  the  increase  and  should  certainly  be  favored 
by  the  fact  that  pregnancy  itself  appears  to  be  passing  more  and  more  into  an 
autotoxic  state  or  states. 

One  aspect  of  the  autointoxication  of  pregnancy  is  intestinal  torpor,  fecal 
stagnation,  stercoremia,  etc. — conditions  which  tend  to  involve  the  appendix 
directly.  An  inflamed  appendix  occurring  in  pregnancy  may  set  up  a  salping- 
itis, and  thereby  pave  the  way  for  certain  forms  of  sep":is  following  labor. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM.  325 

Appendicitis  in  the  pregnant  woman  when  of  mild  degree  might  readily  be 
overlooked  by  confounding  it  with  some  other  local  affection.  In  a  suspected 
case  the  history  of  a  prior  attack  is  of  great  value,  and  with  such  a  history  some 
obstetricians  do  not  hesitate  to  operate  at  once ;  others  choose  an  interval  oper- 
ation after  delivery. 

Aside  from  the  few  preceding  considerations,  appendicitis  in  the  pregnant 
presents  no  differences  from  the  same  affection  in  the  non-pregnant. 

15.  Tapeworm. — Much  distress  and  possibly  interruption  of  pregnancy  may 
be  caused  by  tapeworm  during  pregnancy.  I  have  been  confronted  with 
the  problem  of  treatment  in  cases  of  intense  abdominal  distress  and  insomnia, 
as  anthelmintics  followed  by  the  usual  castor-oil  may  interrupt  pregnancy.  I 
have  observed  decided  symptoms  of  threatened  miscarriage  from  their  use. 
Broadly  speaking,  we  should  wait  until  the  thirty-sixth  week  before  resorting  to 
treatment.  Should  the  health  of  the  patient  be  seriously  compromised  by  the 
presence  of  the  tapeworm,  we  may  be  compelled  to  resort  to  anthelmintic  treat- 
ment earlier,  in  spite  of  the  risk  of  miscarriage. 


XIII.  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

I.  Acute  Endocarditis.  2.  Chronic  Endocarditis.  j.  Affections  of  the  Heart  Muscle.  4. 
Varicosities.  5.  Aneurism.  6.  Palpitation.  7.  Syncope.  8.  Hydrcemia.  g.  Perni- 
cious Anemia.      lo.  Exophthalmic  Goiter. 

1.  Acute  Endocarditis. — This  affection  not  only  has  an  injurious  influence  upon 
pregnancy,  but  it  is  also  apt  itself  to  become  extremely  grave.  Pulmonary 
congestion  is  sure  to  exist  from  the  impeded  action  of  the  heart.  (Edema  of  the 
lungs  causes  the  blood  to  be  dammed  back  on  the  heart,  and  there  result  cardiac 
failure  and  fatal  syncope.  The  most  usual  time  for  the  occurrence  of  this  acci- 
dent is  during  or  just  after  the  birth  of  the  child,  and  it  is  caused  by  the  extra 
strain  on  the  heart,  coincident  with  the  circulatory  changes  due  to  the  lessened 
intra-abdominal  pressure.  Regarding  treatment,  induced  labor  will  be  demanded 
with  the  rapid  emptying  of  the  uterus  after  dilatation,  nitrous  oxide  or  ether 
being  used  if  compensation  is  absent.  Digitalis  is  often  useful  in  the  first  stage 
of  labor,  and  forceps  always  in  the  second.  Moderate  hemorrhage  in  the  third 
stage,  or  just  after  it,  relieves  the  symptoms  of  cardiac  embarrassment.  Nitrite 
of  amyl  has  proved  useful  after  labor. 

2.  Chronic  Endocarditis. — This  is  often  followed  by  a  fatal  termination,  due 
to  the  fact  that  the  hypartrophy  which  already  exists,  and  has  been  sufficient  to 
make  up  for  the  strain  of  pre-existing  valvular  lesions,  is  no  longer  able  to  meet 
the  extra  demands  of  pregnancy.  One  great  danger  in  all  cardiac  cases,  especially 
those  with  acute  symptoms,  is  embolism.  Pulmonary  troubles  are  also  apt  to 
supervene  in  the  last  half  of  pregnancy,  from  exposure  to  cold  or  exertion. 
Pulmonary  congestion  and  oedema  may  occur  with  fatal  result.  Valvular 
disease  may  prove  a  very  unfavorable  complication,  and  this  is  largely  due  to 
the  same  reasons  which  render  the  prognosis  so  unfavorable  in  pneumonia,  and 
also  to  increased  pressure  in  the  blood-vessels,  which  is  incident  to  pregnancy  and 
labor.  Death  is  often  the  result  in  severe  mitral  disease,  the  heart  showing  its 
weakness  especially  after  expulsion  of  the  child  or  placenta.  The  prognosis  is 
unfavorable  for  both  mother  and  child,  although  with  proper  care  many  cases 
will  terminate  favorably ;  placental  apoplexy  and  abortion  are  common.  Mitral 
lesions,  especially  mitral  stenosis,  are  particularly  to  be  dreaded. 


326 


PATHOLOGICAL  PREGNANCY. 


\ 


The  treatment  is  symptomatic  as  regards  the  cardiac  affection.'  The  avoid- 
ance of  overexertion  and  excitement  is  of  the  highest  importance,  and  the 
hygiene  and  nutrition  of  the  patient  should  be  carefully  guarded.  The  induction 
of  labor  must  be  considered  if  the  symptoms  become  very  grave.  Inhalations 
of  nitrite  of  amyl  may  be  of  service  in  cases  of  dyspnea  and  extreme  high  ten- 
sion; stimulants  are  to  be  given  only  if  indicated.  In  cases  of  great  embarrass- 
ment of  the  right  heart,  allowing  the  uterus  to  relax  and  bleed  during  the  third 
stage  will  be  beneficial.  Anesthetics  should  be  used  with  caution,  ether  being 
preferred.  For  obvious  reasons  the  use  of  ergot  is  not  advisable  in  cases  with  a 
tendency  to  contraction  of  the  arterioles.  Syncope  should  be  guarded  against 
by  the  application  of  the  abdominal  binder  before  delivery,  which  is  gradually 
tightened  during  the  emptying  of  the  uterus.     I  have  found  careful  attention  tO' 

nutrition  and  the  secretions,  enforced  rest 
with  massage,  and  the  prolonged  and  free 
use  of  strychnin  of  great  help  in  bringing  a 
case  of  chronic  valvular  disease  to  the  period 
of  viability,  or  even  to  full  term.  During 
labor  I  use  ether,  and  hasten  the  dilatation 
as  much  as  possible  by  bimanual  stretch- 
ing, giving  digitalis  if  indicated,  strychnin 
always,  and  I  always  shorten  the  second 
stage  with  forceps.  Venesection  is  often 
useful. 

3.  Affections  of  the  Heart  Muscle. — There 
can  be  no  doubt  that  in  cases  of  valvular 
lesions  the  hypertrophy,  which  before  preg- 
nancy was  sufficient  for  compensation,  may 
become  insufficient  in  view  of  the  increased 
demand,  and  thus  may  lead  to  serious  symp- 
toms. Fatty  degeneration  may  occur  as  the 
result  of  the  toxemia  of  renal  disease,  or  of 
septic  infection ;  brown  atrophy  has  been  ob- 
served in  a  few  instances.  The  existence  of 
myocarditis  should  cause  grave  apprehen- 
sions, because  the  heart  is  hindered  from 
adequately  developing  to  meet  the  demands 
made  on  it  by  the  valvular  lesions  added  to 
pregnancy, 

4.  Varicosities. — Varicose  veins,  especi- 
ally of  the  thighs  and  lower  gluteal  region,  are 

very  common  (Fig.  472).  Those  of  the  vulva,  vagina,  and  rectum  have  already 
been  noted  (Fig.  466).  Varicosities  also  occur  within  the  pelvis,  especially  in  the 
broad  ligaments,  and  by  their  rupture  may  cause  pelvic  hematocele;  the  occur- 
rence of  hematuria  from  the  rupture  of  varicosities  of  the  bladder  has  been 
noted.  The  chief  caiise  is  the  obstruction  to  the  return  circulation,  by  the  pres- 
sure of  the  gravid  uterus.  Predisposing  causes  are  the  increased  amount  of  blood 
in  the  circulation,  and  changes  in  the  walls  of  the  vessels,  such  changes  being 
favored  by  renal  disease  and  hydrsemia.  Multigravidse  are  more  often  subject 
to  this  trouble  than  arfe  primigravidae.  The  saphenous  vein  is  always  the  first 
vessel  affected.  Pain,  especially  upon  standing  or  walking,  and  with  an  itching 
sensation  over  the  dilated  vein,  are  common  symptoms ;  sensations  of  intrapelvic 
weight  and  pressure  may  occur.     The  prognosis  is  good  with  proper  treatment,. 


Fig.  472. — Varicose  Enlargement 
OF  THE  Left  Saphenous  Vein  in  a 
Pregnant  Woman. 


DISEASES  OF  THE  CIRCULATORY  SYSTEM.  327 

but  the  possible  occurrence  of  rupture  should  not  be  forgotten;  such  an  accident 
may  be  followed  by  most  alarming  hemorrhage.  Thrombosis  and  phlebitis  are 
possible  complications. 

Treatment. — The  patient  and  friends  should  be  warned  of  the  possibility  of 
rupture,  and  should  be  furnished  with  a  compress  and  bandage,  instructed  in  their 
use,  and  how,  in  case  of  hemorrhage,  the  limb  should  be  elevated.  Constipation 
should  be  avoided,  and  the  patient  should  spend  a  good  deal  of  the  time  in  the 
recumbent  position,  with  hips  and  legs  elevated.  Varicosities  of  the  lower 
extremities  should  be  treated  by  the  use  of  properly  fitting  elastic  stockings,  or 
carefully  applied  bandages.  Varicosities  of  the  vulva  should  be  supported  by 
a  pad  and  a  T-bandage.  In  all  cases,  too  much  standing  or  walking  should  be 
avoided,  and  there  should  be  no  constriction  about  the  waist.  An  abdominal 
supporter  may  help  to  prevent  excessive  uterine  pressure  (Fig.  228). 

5.  Aneurism. — This  is  not  common  during  pregnancy,  but  is  of  clinical 
importance,  because  of  the  danger  of  rupture  from  the  straining  efforts  of  the 
second  stage.  The  careful  administration  of  an  anesthetic,  and  the  termination 
of  labor  as  soon  as  is  consistent  with  due  regard  to  the  interest  of  the  mother,  are 
advisable. 

6.  Palpitation. — This  is  a  frequent  occurrence.  It  may  be  of  neurotic  origin 
or  reflex,  from  upward  pressure  of  the  uterus  on  the  diaphragm;  in  many  cases, 
no  doubt,  both  elements  contribute  to  the  causation;  in  the  absence  of  organic 
disease  it  is  not  usually  of  great  importance.  Treatment:  Nerve  sedatives  may 
at  times  be  indicated,  but  as  a  rule  it  is  better  to  attend  to  the  general  hygiene  of 
the  patient  and  the  removal  of  reflex  causes — e.  g.,  constipation.  Moderate  exercise 
in  the  open  air  is  beneficial;  causes  of  excitement  and  worry  should  be  removed 
if  possible.  Should  the  condition  of  high  arterial  tension  exist,  profuse  watery 
stools  produced  by  the  use  of  calomel  and  salines  may  be  required,  and  rest  with 
careful  diet  insisted  upon.  If  the  trouble  is  the  result  of  mechanical  difficulties 
in  the  last  part  of  pregnancy,  hygienic  measures,  together  with  antispasmodics, 
may  give  some  relief,  but  only  when  the  uterus  begins  to  sink  will  permanent 
relief  occur. 

7.  Syncope. — A  special  syncope  of  pregnancy  is  mentioned  by  some  writers 
as  a  manifestation  of  hysteria.     Its  consideration  belongs  under  the  latter  head. 

8.  Hydraemia  ;  Serous  Cachexia;  Serous  Plethora. — An  increased  fluidity  of  the 
blood  was  formerly  supposed  to  exist  during  the  whole  of  pregnancy.  Recent  inves- 
tigations have  tended  to  show  that  in  the  latter  months  the  proportion  of  hemo- 
globin and  the  number  of  red  corpuscles  are  increased.  There  is  no  doubt,  how- 
ever, that  hydremia  does  exist  in  a  large  proportion  of  cases,  especially  in 
ill-nourished  subjects,  in  consequence  of  the  increased  demands  upon  the 
maternal  circulation.  Not  uncommonly  in  hydraemia  there  is  swelling  of  the 
lower  extremities  extending  upward  even  to  the  lower  segment  of  the  uterus. 
If  there  are  no  kidney  complications,  danger  need  not  be  anticipated,  but  the 
discomfort  caused  is  excessive.  Nervous  manifestations  are  common;  there  is  a 
sense  of  fulness  in  the  vessels,  with  disagreeable  pulsation  of  the  arteries;  flashes 
of  heat,  imperfect  vision,  and  dyspnea  are  present;  dull  aching  in  the  sacral 
region,  and  a  diminution  of  the  fetal  movements,  and  even  toxic  symptoms  may 
occur.  The  diagnosis  is  clear  from  the  history  of  the  case  and  from  the  blood- 
examination.  The  latter  reveals  an  abnormal  amount  of  serum,  a  decreased 
number  of  red  blood-cells,  less  albumin  and  iron,  and  increased  fibrin.  The  blood, 
after  being  taken  from  the  vessels,  forms  a  clot  with  abundant  serum  floating 
about  it,  closely  resembling  that  of  chlorosis.  The  whole  amount  of  fluid  is  often 
much  more  than  normal.     The   prognosis  is  generally  good.     The  symptoms 


328  PATHOLOGICAL  PREGNANCY. 

quickly  subside  after  the  child  is  bom,  and  prematurely  induced  labor  is  rarely 
necessary.  The  treatment  consists  in  careful  attention  to  the  secretions;  the 
persistent  administration  of  some  readily  assimilated  preparation  of  iron,  as  the 
peptomanganate  or  albuminate  of  iron,  with  cod-liver  oil;  careful  attention  to  the 
diet ;  forced  feeding  if  necessary ;  massage,  with  a  change  of  air  and  environment. 

9.  Pernicious  Anemia. — This  condition  is  also  known  as  progressive  anemia; 
it  is  of  rare  occurrence,  and  its  etiology  is  obscure.  It  may  be  due  to  a  previous 
anemia  or  chlorosis,  from  whatever  cause;  and  when  once  established,  there  is  a 
continuous  progression  till  death  either  threatens  or  occurs;  no  serous  plethora, 
as  in  hydraemia,  takes  place,  and  there  is  only  a  slight  oedema.  Examination  of  the 
blood  shows  slight  hydraemia,  and  a  diminution  of  albumin  and  of  the  number  of 
red  blood-corpuscles.  There  are  progressive  pallor  and  emaciation,  with  exhaus- 
tion; the  symptoms  resembling  those  of  a  severe  attack  of  chlorosis.  Loss  of 
appetite,  hemorrhages  from  mucous  surfaces,  and  attacks  of  vertigo  and  faint- 
ness  are  common.  The  nervous  system  is  not  well  balanced;  profound  inanition 
may  ensue,  and  the  patient  may  die  comatose.  The  ovum  may  or  may  not 
be  prematurely  expelled.  The  diagnosis  is  simple  and  the  prognosis  bad. 
Everything  possible  should  be  done  to  improve  nutrition;  tonics,  especially  iron, 
should  be  used,  a  reliable  preparation  of  the  peptonate  or  albuminate  being 
usually  preferable ;  arsenic  is  usually  valuable ;  change  of  air  and  scene  may  be 
of  great  service;  the  inhalation  of  oxygen  is  highly  recommended;  correction  of 
the  gastro-intestinal  catarrh  which  frequently  coexists  is  most  important;  the 
induction  of  abortion  may  become  necessary, 

10.  Exophthalmic  Goitre. — In  1895  Theilhaber*  collected  the  reported 
material  on  the  relationship  of  Basedow's  disease  and  pregnancy,  and  the  con- 
nection between  the  same  affection  and  the  puerperium  and  lactation.  In 
pregnancy  a  minority  of  cases  of  coincidence  of  the  two  conditions  shows  that  the 
disease  was  cured  or  improved  by  gestation,  while  in  an  excessive  majority  the 
disease  was  made  worse.  Theilhaber  sees  in  the  relationship  between  Basedow's 
disease  and  pregnancy  a  parallel  to  the  frequent  occurrence  of  neuroses  during 
the  same  condition  (neuralgia,  epilepsy,  chorea,  etc.).  The  relation  between 
Basedow's  disease  and  the  puerperium  is  as  inconstant  as  the  above.  It  has 
frequently  been  observed  that  the  disease  developed  during  the  puerperium  and 
then  subsided,  to  reappear  at  a  subsequent  puerperium;  and  something  of  the 
same  nature  has  been  observed  in  connection  with  lactation.  Kleinwachter 
claimed  that  the  atrophy  of  the  uterus  often  associated  with  Basedow's  disease 
was  of  a  nature  to  exclude  the  possibility  of  gestation;  but  in  a  patient  of  Theil- 
haber the  woman  conceived  after  years  of  uterine  atrophy  and  amenorrhea.  It 
is  best  to  dissuade  girls  with  Basedow's  disease  from  marriage.  Those  already 
married  should  be  forbidden  to  conceive,  for  the  good  reason  that  both  gravidity 
and  the  puerperium  frequently  aggravate  the  disease  greatly,  and  that  the  off- 
spring of  such  women  are  often  highly  neuropathic.  On  the  other  hand,  if 
pregnancy  is  already  established,  the  prognosis  is  not  sufficiently  grave  to  indicate 
its  interruption  unless  the  cardiac  musculature  is  seriously  compromised.  In 
cases  of  child-birth  in  these  goitre  subjects  prolonged  lactation  is  contraindicated. 

*  "Arch.  f.  Gynakol.,"  1895. 


DISEASES  OF  THE  RESPIRATORY  SYSTEM.  329 


XIV.  DISEASES  .OF  THE  RESPIRATORY  SYSTEM. 

/.  Hyperosniia.  2.  Broncliitis.  j.  Pneumonia.  4.  Emphysema.  5.  Pleurisy.  6. 
Hemoptysis.  7.  Pulmonary  Tuberculosis.  8.  Acute  Miliary  Tuberculosis,  g.  Dyspnea 
of  Pregnancy.      10.  Nervous  and  Spasmodic  Cough.      11.  Asthma. 

1.  Hyperosmia. — Pregnant  women  of  nervous  temperament  are  sometimes 
annoyed  by  an  abnormal  development  of  the  sense  of  smell.  Unpleasant  odors 
should  be  avoided  as  far  as  possible,  and  pleasing  ones  substituted,  as  the  condi- 
tion may  predispose  to  nausea  and  vomiting,  and  even  be  an  important  factor  in 
the  production  of  the  pernicious  vomiting  of  pregnancy. 

2.  Bronchitis.- — During  pregnancy  this  is  of  no  special  significance,  except 
that  violent  coughing  may  induce  abortion.  In  all  respiratory  diseases,  however, 
it  should  be  remembered  that  the  hydraemia  of  pregnancy  predisposes  to  pul- 
monary oedema. 

3.  Pneumonia. — (See  Infectious  Diseases.) 

4.  Emphysema. — This  frequently  occurs  in  an  aggravated  form,  and  may 
cause  abortion,  from  the  retention  of  carbonic  acid  gas  in  the  blood;  the  influ- 
ence of  this  gas  in  causing  uterine  contractions  is  noted  in  connection  with  the 
etiology  of  abortion.  Symptomatic  treatment,  with  counterirritation  of  the 
chest,  is  indicated.  It  is  possible  that  the  inhalation  of  oxygen,  from  the  relief 
it  affords,  may  tend  to  prevent  abortion.  Careful  watch  must  be  kept  for 
symptoms  of  weakening  heart,  and  should  they  ensue  artificial  labor  may  be 
demanded. 

5.  Pleurisy  with  effusion,  owing  to  the  diminished  breathing  space,  and  the 
additional  work  thrown  upon  the  heart,  is  a  dangerous  complication  of  pregnancy. 
If  the  effusion  becomes  purulent  (empyema),  the  danger  is  manifestly  increased. 
If  the  condition  can  be  relieved  by  the  evacuation  of  fluid,  by  aspiration  or  other- 
wise, the  procedure  is  imperatively  indicated;  otherwise  the  treatment  is  symp- 
tomatic. 

6.  Hemoptysis  may  occur,  in  connection  with  overaction  of  the  heart, 
during  the  last  few  months  of  pregnancy,  without  organic  pulmonary  disease, 
and  is  most  common  in  women  of  highly  nervous  temperament.  The  treatment 
should  include  absolute  rest  and  quiet,  and  the  use  of  sedatives,  particularly  the 
bromides. 

7.  Tuberculosis  and  Pregnancy. — The  subject  of  the  relationship  between 
tuberculosis  and  pregnancy  has  recently  attained  an  increased  degree  of  impor- 
tance, through  the  agitation  in  favor  of  the  justification  of  abortion  in  the  tubercu- 
lous pregnant  woman.  A  sort  of  traditional  view  still  exists  in  the  minds  of 
some  medical  men  and  laymen,  that  pregnancy  may  sometimes  arrest  the  devel- 
opment of  consumption. 

Pregnancy  a  Predisposing  Cause  of  Tuberculosis. — Statistics  appear  to 
show,  according  to  Lancereaux,  that  a  considerable  number  of  cases  of  tubercu- 
losis develop  solely  as  a  result  of  pregnancy.  The  morbific  action  of  the  bacillus 
is  not  discredited  by  this  statement,  which  simply  means  that  the  woman  who 
became  tuberculous,  had  no  family  history  of  the  disease,  was  not  of  the  scrofulous 
or  tuberculous  habit,  had  never  been  exposed  to  the  hazard  of  contagion,  and 
was  living  at  the  time  of  the  infection  in  a  good  sanitary  environment.  Assum- 
ing, as  Lancereaux  does,  that  the  bacillus  is  omnipresent,  we  must  conclude  that 
pregnancy  by  itself  can  render  a  healthy  individual  "  tuberculizable. "  If  preg- 
nancy can  thus  affect  the  healthy,  how  much  more  likely  would  it  be  for  the 
disease  to  assert  itself  in  a  woman  who  is  a  fit  subject  for  it,  or  in  one  who  is 


330  PATHOLOGICAL  PREGNANCY. 

actually  consumptive?  In  the  former  class  are  so-called  "  candidates  for  tuber- 
culosis," who  have  a  family  history  of  the  disease,  of  much  significance  under 
these  circumstances ;  one  should  strongly  dissuade  girls  with  tuberculous  history 
and  antecedents  from  early  marriage,  fearing  that  rapid  child-bearing  will  infalli- 
bly light  up  the  dreaded  malady.  What  has  been  said  of  the  "candidates  for 
tuberculosis  "  applies  with  the  same  or  greater  force  in  the  case  of  so-called  latent 
tuberculosis,  and  of  apparent  recovery  from  the  disease.  It  must  not  be  under- 
stood that  exceptions  may  not  occur,  and  that  tuberculous  suspects  necessarily 
become  phthisical  after  pregnancy.  The  influence  of  pregnancy,  whether  single 
or  repeated,  upon  such  women  represents  a  tendency  rather  than  a  law,  but  the 
physician's  responsibility  is  not  lessened  by  this  fact,  and  he  must  necessarily  be 
something  of  an  alarmist,  in  order  to  advise  his  patients  upon  the  safe  side.  The 
circumstances  and  environment  of  the  woman,  and  the  general  prognosis  of  preg- 
nancy, aside  from  the  question  of  tuberculosis,  should  have  great  significance  in 
the  matter  of  forbidding  or  interrupting  a  pregnancy.  In  a  case  of  uncontrollable 
vomiting,  for  example,  the  fact  that  the  woman  is  a  tuberculous  suspect  would 
have  much  weight  in  influencing  the  physician  to  interrupt  the  pregnancy. 
Future  generations  must  decide  as  to  whether  pregnancy  in  the  tuberculous 
woman  should  be  interrupted  as  a  routine  procedure.  Present  sentiment  is  be- 
ginning to  dissuade  such  women  from  marriage,  not  less  for  their  own  benefit 
than  for  the  sake  of  posterity,  and  all  organized  movements  which  are  seeking  to 
eradicate  tuberculosis  from  the  world  lay  much  stress  .on  discouraging  marriage 
in  tuberculous  suspects.  As  long  as  this  view  prevails,  there  will  necessarily  be 
some  justification  for  interrupting  pregnancy  already  under  way. 

On  the  other  hand,  it  is  claimed  that  incipient  phthisis  is  no  longer  a  fatal 
affection,  and  that  two-thirds  or  more  of  such  cases  may  be  cured,  or  at  least 
brought  to  a  standstill.  If  this  view  be  accepted,  we  have  no  statistical  evidence 
to  show  that  consumption  which  develops  during  pregnancy  may  be  cured  or 
arrested.  If  the  disease  develops  early  in  pregnancy,  the  woman  must  go  on  for 
a  number  of  months  before  she  can  become  a  fit  subject  for  treatment,  and  this 
delay  would  of  course  militate  greatly  against  her  chances  of  recovery.  Sana- 
toria for  consumptives  do  not  care  to  admit  pregnant  women,  and  this  prohibi- 
tion is  equivalent  to  ranking  them  as  incurable.  It  cannot  be  denied  that  such  a 
custom  as  the  induction  of  abortion,  in  mere  tuberculous  suspects,  might  readily 
become  a  source  of  abuse,  by  furnishing  a  pretext  for  malpractice;  but,  at  the 
same  time,  the  fact  that  a  candidate  for  tuberculosis  runs  a  very  great  risk  of 
becoming  a  consumptive  through  child-birth  is  a  most  stubborn  one,  and  when, 
in  addition  to  becoming  a  consumptive  herself,  she  also  brings  into  the  world  an 
individual  who  is  likely  to  become  tuberculous,  it  readily  becomes  apparent  that 
the  question  of  the  propriety  of  therapeutic  abortion  is  bound  to  become  an  issue 
in  the  future,  in  the  practice  of  obstetrics. 

Pregnancy  and  Actual  Tuberculosis. — As  a  general  rule,  gestation 
exerts  a  distinctly  unfavorable  influence  upon  the  disease.  The  presence 
of  the  gravid  uterus  interferes  with  respiration  and  the  aeration  of  the 
blood,  while  the  nausea  and  vomiting  of  pregnancy  tend  to  interfere  with  assim- 
ilation. Despite  the  fact  that  a  pregnancy  is  often  sufficient  to  bring  about 
tuberculosis,  it  cannot  be  said  that  an  incipient  case  of  the  latter  is  much  acceler- 
ated by  one  parturition.  As  a  general  rule,  it  may  be  stated  that  the  more 
advanced  the  pulmonary  mischief,  the  greater  the  untoward  effects  of  child- 
birth. Generally  speaking,  the  ill  effects  of  pregnancy  are  not  apparent  during 
the  very  first  months,  and  some  observers  regard  the  fifth  month  as  the  period  at 
which  the  course  of  the  disease  is  seen  to  be  modified  by  the  woman's  condition. 


DISEASES  OF   THE  RESPIRATORY  SYSTEM.  331 

However,  the  danger  to  the  woman  is  present  not  alone  through  the  course  of 
the  pregnancy,  but  in  the  puerperium  as  well.  A  tuberculous  woman  may  go 
through  gestation  with  no  undue  acceleration  of  her  malady,  only  to  succumb, 
after  delivery,  to  acute  general  tuberculosis  or  acute  tuberculous  pneumonia. 

Some  forms  of  pulmonary  tuberculosis  are  much  less  influenced  by  pregnancy 
than  others,  and  it  is  generally  held  that  the  so-called  fibroid  phthisis  is  hardly 
modified  at  all,  either  during  gestation  or  after  delivery.  This  important  fact 
should  be  borne  in  mind  in  practice,  because  a  woman  with  fibroid  phthisis  is 
probably  capable  of  child-bearing.  In  sharply  localized  tuberculosis  the  effect  of 
pregnancy  by  itself  does  not  appear  to  be  unfavorable,  and  it  is  even  claimed  that 
the  woman  with  such  a  lesion  is  better  during  gestation.  The  efforts  of  the  lungs, 
cramped  as  they  are  by  the  gravid  uterus,  to  obtain  oxygen  constitute  a  species  of 
pulmonary  gymnastics,  and,  as  a  result,  the  tuberculous  focus  does  not  increase 
in  size.  But  the  situation  may  change  immediately  after  delivery.  The  great 
strain  of  labor  appears  to  mobilize  the  bacillus.  The  loss  of  blood,  and  the 
shock  and  fatigue,  lower  the  resistance.  The  stimulus  to  forced  inspiration  is 
no  longer  present.  Under  all  these  circumstances  the  local  process  may  suddenly 
increase,  and  an  acute  infection  of  the  lung  tissue,  or  generalization  of  the  tuber- 
culous disease,  may  occur.  The  claims  made  by  Pinard  and  other  observers, 
that  phthisis  may  undergo  spontaneous  resolution  during  pregnancy,  may  pos- 
sibly rest  upon  an  erroneous  interpretation  of  facts,  and  in  any  case  such  a 
sequence  must  be  very  rare.  If  spontaneous  recovery  does  occur,  it  is  prob- 
ably in  cases  of  single  and  sharply  circumscribed  foci  of  disease. 

Obstetric  treatment  has  now  come  to  be  regarded  as  the  proper  course,  theo- 
retically at  least,  but  meets  with  considerable  opposition  and  even  condemnation 
from  conservative  sources.  Bossi,  who  has  practised  this  form  of  intervention  for 
ten  years,  has  had  only  about  twenty  cases  to  his  credit ;  whence  it  is  to  be  inferred 
that  the  necessity  for  intervention  does  not  arise  so  often  as  one  would  naturally 
suppose.  Results  appear  to  show  that  when  done  under  favorable  circumstances 
— general  condition  fairly  good,  pregnancy  not  very  far  advanced — intervention 
holds  the  disease  in  check  to  a  decided  extent.  While  these  women  often  bear 
healthy  and  well-nourished  children,  a  comparison  of  the  issue  of  phthisical  indi- 
viduals with  those  of  healthy  stock  will  show,  on  the  part  of  the  former,  an  in- 
feriority in  size  and  weight,  and  a  greater  vulnerability  and  mortality  early  in 
life;  and  all  this  irrespective  of  the  prospect  of  developing  some  tuberculous 
disease.     Tuberculous  pregnant  women,  also,  show  no  little  tendency  to  abort. 

8.  Acute  miliary  tuberculosis  occurring  during  pregnancy  is  a  rapidly  fatal 
disease  and  is  frequently  mistaken  for  septic  infection. 

9.  Dyspnea  of  Pregnancy. — This  condition  is  marked  by  paroxysms  resem- 
bling those  of  spasmodic  asthma,  and  occurs  most  frequently  in  patients  of  ner- 
vous temperament.  Dyspnea  from  purely  mechanical  causes,  such  as  upward 
pressure  upon  the  diaphragm,  frequently  occurs  in  the  later  months  of  pregnancy, 
and  can  best  be  relieved  by  loose  clothing  and  the  avoidance  of  constipation.  It 
usually  disappears  spontaneously  with  the  descent  of  the  uterus,  which  takes 
place  at  the  onset  of  the  preparatory  stage  of  labor  about  two  weeks  before  term. 
Antispasmodics  and  nerve  sedatives,  and  in  severe  cases  the  inhalation  of 
oxygen,  are  useful. 

10.  Nervous  and  Spasmodic  Cough. — Coughing  of  reflex  origin  and  without 
organic  change  in  the  respiratory  tract  sometimes  occurs  in  pregnant  women, 
especially  those  of  nervous  temperament.  The  paroxysms  maybe  so  severe  as  to 
induce  abortion.  It  is  best  treated  by  nerve  sedatives,  such  as  the  bromides, 
chloral,  valerian,  and  asafetida,  and  by  the  removal  of  the  reflex  causes;  i.  e.. 


332  PATHOLOGICAL   PREGNANCY. 

constipation,  granulations  or  erosions  of  the  cervix.  In  a  severe  case  which 
resisted  all  other  treatment,  I  obtained  a  cure  at  the  sixth  month  by  curetting 
away  granulations  from  the  vaginal  portion  of  the  cervix  and  cervical  canal,  and 
touching  all  raw  surfaces  thus  produced  with  pure  carbolic  acid.  Pregnancy 
was  not  in  any  way  interfered  with. 

II.  Asthma. — In  asthmatic  subjects  the  paroxysms  are  exceptionally  severe 
during  pregnancy,  and  demand  the  same  treatment  as  in  the  non-pregnant  state, 
oxygen  being  of  great  value.  Certain  women  have  asthma  only  in  pregnancy, 
and  the  appearance  of  a  paroxysm  then  becomes  evidence  of  the  patient's  condi- 
tion. The  general  prognosis  is  somewhat  unfavorable  for  mother  and  child. 
Fetal  and  maternal  death  have  occurred  as  a  direct  result  of  asthma,  and  thera- 
peutic abortion  is  sometimes  required.* 


XV.  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Z.  Cerebral  Disease.  2.  Gestational  Melancholia,  Mania,  and  Dementia,  j.  Vertigo  and 
Syncope.  4.  Insomnia.  5.  Gestational  Paralysis.  6.  Gestational  Neuralgias.  7.  Neu- 
roses. 

1.  Cerebral  Disease. — Apoplexy  has  little  influence  upon  the  course  of  either 
gestation  or  labor.  Inflammatory  diseases  are  rare  and  accidental,  and  their 
influence  upon  the  course  of  pregnancy  is  slight,  except  in  the  case  of  cerebro- 
spinal meningitis;  since  this  latter  is  infectious,  it  has  an  effect  upon  pregnancy 
similar  to  other  infectious  fevers. 

2.  Gestational  Melancholia,  Mania,  and  Dementia. — Insanity  rarely  has  its 
origin  during  pregnancy,  but  may  occur  and  present  the  types  of  mel- 
ancholia, mania,  or  dementia,  the  most  common  type  being  melancholia  with 
a  tendency  to  self-destruction.  This  rarely  appears  until  the  second  third  of 
gestation,  and  is  most  common  in  elderly  primigravidce,  especially  the  unmarried. 
The  causes  are  pre-existence  or  predisposition,  excessive  fright,  and  prolonged 
anxiety. 

Maternity  Insanity  in  General. — The  term  puerperal  insanity  has  been  generally  used 
in  such  a  sense  as  to  comprise  any  psychical  disturbances  which  antedate  or  follow  the 
puerperium,  within  certain  limits.  This  notion,  according  to  the  alienists,  is  loose  and  un- 
scientific. The  term  puerperal  insanity  should  be  restricted  to  manifestations  which  develop 
within  from  four  to  six  weeks  after  labor,  or,  in  other  words,  during  the  period  of  the  lochia! 
discharge.  The  complete  relationship  between  child-bearing  and  insanity  should  be  re- 
garded as  follows:  (i)  Course  of  pregnancy,  etc.,  in  the  known  insane.  (2)  Insanity  of 
pregnancy.  (3)  Insanity  of  the  puerperium.  (4)  Insanity  following  the  puerperium 
(lactation  insanity) .  (5)  To  these  might  be  added  a  fifth  type  occurring  during  the  act  of 
labor,  from  the  high  degree  of  suffering — insanity  (delirium)  during  labor.  In  regard  to  the 
frequency  of  these  types  of  insanity,  it  is  claimed  by  alienists  that  some  10  per  cent,  or  15  per 
cent,  of  all  the  female  insane  who  require  asylum  treatment  derive  their  condition  in  some 
way  from  maternity.  According  to  Abt,  if  15  per  cent,  of  insanity  is  due  to  maternity,  the 
individual  frequency  would  be  as  follows:  insanity  of  pregnancy,  2  per  cent.;  insanity  of 
puerperium,  9  per  cent.;  insanity  of  lactation,  4  per  cent.  These  figures,  however,  have  a 
limited  value,  for  many  cases  of  maternity  insanity  are  so  mild  and  transient  that  no  incar- 
ceration is  required.  It  appears  safe  to  say  that  puerperal  insanity,  in  the  narrower  sense,  is 
the  prevalent  form,  a  fact  not  without  significance  in  connection  with  the  theory  that  there 
is  some  relationship  between  this  type  of  psychosis  and  sepsis. 

General  Etiology  of  Maternity  Insanity.— 'R.ega.rd.ed.  independently  of  the  particular  phase 
of  these  psychoses,  the  chief  etiological  element  is  doubtless  heredity;  the  proportion  of  such 
cases  amounting  to  not  less  than  one-half.  In  this  connection,  acquired  insanity  must  also 
be  mentioned  as  a  factor.  This  condition  may  develop  in  those  of  sound  heredity,  as  a  result 
of  acute  infectious  diseases,  violent  mental  emotions,  acute  physical  overstrain,  etc. 

General  Symptomatology. — This  subject  should  likewise  be  considered  without  regard  to 

*  Audebert:  Paris  Intemat.  Congress,  iqoo. 


DISEASES  OF  THE  NERVOUS  SYSTEM.  333 

any  individual  phase  of  maternity  insanity.  The  symptoms  are  present  in  great  variety, 
and  all  the  familiar  types  of  insanity  are  found  within  the  domain  of  our  present 
subject.  Insanity  of  the  depressive  type,  including  melancholia,  hypochondria,  and 
imaginary  fears,  is  sufficiently  well  represented.  The  melancholic  type  frequently 
exhibits  a  religious  color,  expressed  by  self-reproach,  etc.  The  opposite  type  of  mania 
is  also  common,  with  its  exaltation,  and  increased  bodily  and  mental  activity.  The 
expression  of  the  latter  may  be  harmless,  consisting  in  mere  pronounced  eccentricity 
of  various  kinds;  but  it  is  also  often  violent,  so  that  restraint  becomes  necessary. 
Formerly  comprised  under  mania,  but  now  placed  in  a  special  category,  is  the  hallucinatory 
type.  Here  there  is  neither  exaltation  nor  depression,  but  the  patient  is  simply  deceived  by 
her  perceptive  faculties.  The  state  is  therefore  one  of  extreme  confusion.  Unrecognized  or 
improperly  treated,  this  type  of  insanity  might  become  coequal  in  its  results  with  mania. 
The  impulses  of  the  victim  of  maternity  insanity  to  destroy  herself,  her  children,  or  others, 
are  now  placed  under  the  head  of  imperative  conceptions,  not  necessarily  connected  or  asso- 
ciated with  any  of  the  basic  types  of  insanity.  These  phenomena  are  said  to  be  noted  par- 
ticularly when  an  inherited  taint  is  present,  and  often  they  are  the  first  expression  of  such 
inheritance.  The  further  discussion  of  these  insanities  is  continued  under  the  special  forms, 
and  they  are  once  more  brought  together  under  the  head  of  treatment. 

Etiology. — Gestation  may  either  awaken  a  hereditary  taint  of  insanity,  or  the 
psychosis  may  develop  de  novo.  In  the  latter  case  the  resulting  mental  state  may 
be  regarded  as  an  exaggeration  of  the  disturbances  of  psychical  equilibrium, 
so  common  in  pregnancy,  and  in  connection  with  menstruation,  especially  at  the 
time  of  the  establishment  of  that  function.  This  type  of  pregnancy  psychosis 
then,  is  the  least  removed  from  the  physiological  status.  The  disturbed  psychi- 
cal and  nervous  equilibrium  so  common  in  pregnancy  would,  in  itself,  occurring 
apart  from  that  condition,  constitute  a  mild  type  of  psychopathy  and  neuropathy. 
We  have  only  to  call  attention  to  the  unnatural  cravings,  the  blunting  and  per- 
version of  taste  and  smell,  the  pretematurally  acute  sight  and  hearing,  the  re- 
markable changes  in  disposition,  amounting  almost  to  a  reversal  of  temperament 
and  transformation  of  character,  etc.  This  type  of  insanity  often  appears  to 
have  a  physical  basis,  and  to  stand  in  close  relationship  with  anomalies  of  circu- 
lation, as  shown  by  the  very  commonly  encountered  attacks  of  vertigo  and 
fainting.  Aside  from  the  general  causal  factors  already  enumerated,  a  special 
factor  is  found,  in  the  case  of  pregnancy  insanity,  in  the  shock  and  perturbation 
induced  by  the  realization  of  the  fact  that  conception  has  occurred.  This  factor 
obtains  chiefly  in  the  unmarried,  and  in  married  women  who,  from  any  reason, 
can  ill  afford  to  submit  to  pregnancy.  Death  of  a  near  relative  during  preg- 
nancy may  have  a  similar  effect. 

Symptoms. — Since  the  eccentricities  of  pregnant  women  are  commonly 
understood,  the  borderland  of  insanity  is  frequently  overlooked,  and  opportuni- 
ties for  arresting  the  condition  are  consequently  forfeited.  An  act  of  violence  of 
some  sort  is  the  first  intimation  of  the  true  state  of  the  woman's  mind.  Many  of 
the  milder  cases  are  so  slight  in  degree,  and  of  so  short  a  duration,  that  they  pass 
unrecognized,  and  thus  help  to  invalidate  the  statistics  of  frequency  and  severity. 
As  a  rule,  the  character  of  the  psychoses  of  the  early  months  of  pregnancy  is  of 
the  depressive  type;  and,  generally  speaking,  psychoses  which  supervene  early 
in  pregnancy  tend  to  become  worse  with  the  aggravation  of  the  physical  condi- 
tions. Further,  the  numerous  severe  physical  disturbances  and  diseases  which 
may  develop  as  pregnancy  advances  have  a  distinct  tendency  to  aggravate  the 
psychosis,  causing  it  to  pass  into  a  more  severe  and  pernicious  type.  Psychoses 
of  pregnancy  are  prone  to  be  continued  after  delivery ;  a  tendency  which  illustrates 
the  futility  of  bringing  on  abortion  under  the  circumstances.  Imperative  con- 
ceptions are  prone  to  supervene  during  pregnancy,  and  they  should  be  sharply 
watched  for,  in  all  pregnant  women  of  psychopathic  or  degenerate  stock.  These 
conceptions,  held  under  control  by  the  will  before  pregnancy,  begin  at  this 
period  to  be  irresistible.     Many  of  the  morbid  "  phobias,"  so  common  in  neuras- 


334  PATHOLOGICAL  PREGNANCY. 

thenia,  are  also  encountered  under  these  circumstances  for  the  first  time.  This 
sudden  impairment  of  mental  equilibrium  appears  to  be  due  in  many  cases  to  the 
presence  of  vomiting,  vertigo,  and  the  like.  The  impulses  to  homicidal  or 
suicidal  violence,  in  the  case  of  these  women,  often  comes  from  the  sight  of  a 
knife  or  other  lethal  weapon;  or  of  an  open  window,  etc.  In  some  cases  the 
women  themselves  confess  to  the  presence  of  these  impulses,  while  they  are  still 
able  to  master  them. 

Treatment. — The  keynote  of  successful  treatment  lies  in  early  recognition  of 
the  psychosis.  Prophylactic  and  general  regimen  comprises  sufficient  feeding, 
together  with  proper  attention  to  all  existing  physical  disorders.  When  the 
diagnosis  is  made,  an  alienist  should  be  summoned  in  consultation.  Hypnotics 
should  be  promptly  administered,  in  the  hope  of  procuring  sleep  and  of  control- 
ling the  attack.  When  the  general  practitioner  is  obliged  to  depend  upon  him- 
self, no  alienist  or  asylum  being  available,  he  can  but  carry  out  three  general 
principles,  without  reference  to  the  considerations  which  attend  a  nice  diagno- 
sis. The  patient  must  be  (i)  nourished,  she  must  be  made  to  (2)  sleep,  and 
finally  she  must  be  (3)  prevented  from  inflicting  injury  upon  herself,  her  child, 
or  others.  She  should  be  kept  upon  the  ground  floor  of  the  house,  and  all 
lethal  weapons,  drugs,  chemicals,  etc.,  kept  out  of  reach.  She  should  be  kept 
in  bed,  and  the  bedding  searched  twice  daily  for  secreted  articles,  which 
might  be  used  with  suicidal  intent.  The  services  of  a  good  nurse  are  all- 
important.  To  restrain  motor  excitement,  and  thereby  limit  the  danger  of 
suicide,  opiates  are  indicated,  and  in  high  degrees,  morphin  and  hyoscin 
hypodermically.  To  secure  sleep  all  external  conditions  must  be  made  as 
favorable  as  possible,  after  which  any  good  hypnotic,  such  as  trional  or  chloral- 
amid,  is  indicated.  If  the  patient  will  eat,  she  should  be  fed  freely  with  simple, 
nutritious  articles  and  weighed  frequently.  If  food  is  refused,  the  stomach-tube 
must  be  employed. 

Various  important  questions  arise  in  connection  with  the  management  of  this 
affection,  (i)  Asylum  treatment:  While  indicated  in  theory,  this  resource  is 
directly  contraindicated  in  practice,  for  the  chances  are  that  the  patient  will 
quickly  recover  and  will  never  forgive  her  medical  attendant  for  the  stigma 
brought  upon  her  (as  she  believes)  by  incarceration  in  an  institution.  The 
patient  should  instead  have  a  trained  attendant,  and  convalescence  maybe  has- 
tened by  travel.  (2)  Interruption  of  pregnancy:  This  is  never  indicated,  for 
the  very  good  reason  that  it  does  not  restore  the  patient's  mind  to  the  natural 
state.  (3)  Lactation:  The  patient  should  never  nurse  her  child  and  the  secretion 
of  milk  should  be  suppressed  as  soon  as  possible.  (4)  The  element  oj  sepsis:  The 
possibility  that  puerperal  mania  may  have  a  septic  element  should  be  utilized  in 
every  possible  way  in  the  management  of  a  case.  The  patient  should  have  her 
parturient  tract  thoroughly  examined. 

3.  Vertigo. — We  often  observe  a  dizziness  in  highly  nervous  and  hysterical 
women,  independent  of  the  toxemia  of  pregnancy.  It  must  be  remembered 
that  an  exaggeration  of  the  usual  hydraemia  and  anemia  of  gestation  is  often  the 
real  underlying  cause,  and  can  be  relieved  by  attention  to  the  blood  conditions 
present. 

4.  Insomnia. — Insomnia  may  occur  with  circulatory  changes,  or  independent 
of  them,  due  to  the  toxemia  of  pregnancy.  When  the  former  is  the  cause,  the 
treatment  consists  in  cathartics,  diuretics,  and  diaphoretics.  In  other  cases  it  is 
necessary  carefully  to  regulate  the  diet,  and  to  use  nerve  sedatives  or  anti- 
spasmodics, such  as  the  bromides,  sulphonal,  camphor,  valerian,  and  asafetida, 
care  being  taken  to  prevent  a  drug  habit. 


DISEASES  OF   THE  NERVOUS  SYSTEM.  335 

5.  Gestational  Paralyses. — Paralyses  in  pregnancy  are  sometimes  incorrectly 
termed  puerperal  paralyses.  The  nerves  of  special  sense,  or  the  facial  nerves, 
may  be  affected,  or  hemiplegia  or  paraplegia  may  occur.  Paralyses  of  the  nerves 
of  special  sense  may  result  in  amaurosis  or  deafness,  partial  or  complete.  In  the 
case  of  amaurosis,  kidney  insufficiency  should  always  be  suspected.  Anemia  of 
the  retina  may  be  the  cause,  and  if  injury  to  the  latter  has  not  occurred,  the  pre- 
mature interruption  of  pregnancy  will  result  in  a  cure.  Deafness  is  a  rare  and 
temporary  condition,  and  may  be  either  unilateral  or  bilateral;  it  may  or  may  not 
be  due  to  renal  insufficiency.  Facial  paralysis  is  extremely  rare,  and  is  usually 
the  result  of  profound  anemia.  Hemiplegia  is  not  uncommon  in  pregnancy;  it 
may  be  caused  by  cerebral  hemorrhage  or  anemia,  and  does  not  necessarily  inter- 
fere with  pregnancy  or  parturition.  Paraplegia  may  be  the  result  of  a  spinal 
disease,  or  of  pressure  upon  the  pelvic  nerves  by  the  fetal  head;  the  loss  of  volun- 
tary motion  thus  produced  does  not  necessarily  interfere  with  pregnancy  or 
labor.  Both  these  conditions  may  demand  the  premature  interruption  of  preg- 
nancy, in  addition  to  the  use  of  strychnin,  faradization  of  the  affected  limbs, 
and  iron.  Both  hemiplegia  and  paraplegia  are  apt  to  disappear  in  the  puer- 
perium. 

6.  Gestational  Neuralgias. — Neuralgic  pains  in  various  parts  of  the  body,  the 
uterus  not  excepted,  are  common.  Toothache  is  often  met  with,  and  may  be  of 
functional  or  organic  origin  (see  page  321).  Neuralgias  of  the  lumbar  and  recti 
muscles  are  also  common,  the  latter  being  due  to  excessive  stretching;  sciatica 
often  occurs  in  the  latter  part  of  gestation,  as  a  result  of  pressure.  Headache, 
when  present,  should  always  make  us  suspicious  of  renal  insufficiency,  as  should 
localized  neuralgic  pains  in  the  head,  face,  or  breast,  which  are  often  symptoms 
of  advanced  renal  disease  in  pregnancy. 

The  treatment  consists  in  careful  attention  to  the  excretions,  especially 
those  of  the  bowels  and  kidneys,  and  in  the  use  of  external  and  internal  pallia- 
tive measures,  such  as  sedative  applications,  nerve  sedatives,  and  antispasmodics. 

7.  Neuroses. — Hysteria  is  more  or  less  common  in  all  pregnant  women.  The 
existence  of  pregnancy  renders  the  mental  balance  of  the  woman  unstable,  and 
an  hysterical  attack  may  be  precipitated  on  the  slightest  occasion.  True  insanity 
has  developed  as  a  sequela.  Syncopal  attacks  and  hyperemesis  are  both  regarded 
as  of  hysterical  origin  in  many  cases.  The  treatment  is  that  of  hysteria  in 
general.     Moral  suasion  is  far  more  effective  than  are  drugs. 

Epilepsy  is  a  rare  complication,  because  epileptics  are  usually  sterile,  and  if 
gestation  does  occur,  are  often  free  from  an  attack  during  pregnancy,  the  disease 
returning  in  the  lying-in  state.  It  may  be  confounded  with  an  eclamptic  attack 
(see  Eclampsia).  Children  born  of  epileptics  usually  die  of  congenital  epilepsy 
when  quite  young. 

Chorea  in  its  milder  grades  is  not  uncommon;  the  causes  being  chlorosis, 
rheumatism,  and  heredity.  Sixty  per  cent,  of  the  cases  occur  in  primigravidse. 
It  usually  appears  in  the  first  third  of  gestation,  and  shows  a  tendency  to  persist; 
it  is  observed  only  during  the  waking  hours,  but  if  it  is  severe  and  persistent,  inter- 
ruption of  pregnancy  occurs.  The  maternal  mortality  is  as  high  as  30  per  cent. 
Gestational  insanity  is  often  a  sequela.  The  causes  of  death  are  muscular  exhaus- 
tion, heart  failure,  insanity,  or  the  sequelae  of  an  interrupted  pregnancy.  The 
treatment  in  the  milder  cases  consists  of  arsenic,  given  to  the  physiological  point, 
iron,  good  hygiene,  and  carefully  regulated  diet.  Severe  cases,  with  tetany  as  a 
complication,  may  require  anesthesia.  The  induction  of  premature  labor 
usually  results  in  a  spontaneous  cure. 


336  PATHOLOGICAL  PREGNANCY. 


XVI.  INFECTIOUS  DISEASES. 

/.   Variola.       2.  Scarlatina.       j.  Measles.        4.    Typhoid.         5.    Typhus.         6    Erysipelas. 
7.    Malaria.       8.  Pneumonia.       g.  Syphilis. 

These  affections  are  also  considered  fully  under  the  pathology  of  the  fetus 
(page  255).  In  the  present  connection  they  are  briefly  treated  from  the  maternal 
side. 

1.  Variola. — This  tends  to  run  a  severe  course  in  the  pregnant  woman,  cases 
of  the  confluent  and  hemorrhagic  types  being  specially  common.  But  mild 
cases,  of  course,  occur  in  mild  epidemics  and  in  individuals  protected  in  part  by 
vaccination.  Metrorrhagia  occurs  at  times,  and  not  necessarily  in  hemorrhagic 
cases.  The  frequency  with  which  abortion  occurs  is  directly  proportional  to  the 
intensity  of  the  disease.  It  is  inevitable  in  the  hemorrhagic  type,  almost  inevit- 
able in  the  confluent  type,  but  occurs  only  in  a  minority  of  cases  when  the 
disease  is  benign.  Prophylaxis  and  treatment  call  for  no  special  mention  here. 
Pregnant  women  should  invariably  be  vaccinated  under  the  same  conditions  as 
other  indviduals. 

2.  Scarlatina. — This  is  considered  elsewhere  as  a  puerperal  disease  (Part  VII). 
As  a  complication  of  pregnancy  alone  it  is  of  rare  occurrence,  the  gravid  woman 
enjoying  a  relative  immunity  in  comparison  with  the  puerpera.  Certain  obstetri- 
cians hold  that  the  disease  may  be  latent  during  pregnancy,  to  assert  itself  after 
delivery.  This  is  a  mere  opinion  at  present.  Another  view  is  that  the  exposed 
pregnant  woman  may  transmit  the  disease  to  the  fetus  without  herself  becoming 
infected.  Scarlatina  which  breaks  out  during  pregnancy  runs  its  course  as  in  the 
non-pregnant.     If  the  degree  of  infection  is  intense,  abortion  results. 

3.  Measles. — This  is  rarely  described  as  a  complication  of  pregnancy.  The 
gravid  have  no  special  immunity  toward  measles,  but  are  chiefly  protected  by 
having  had  the  disease  in  childhood.  The  course  of  the  disease  appears  to  be 
identical  in  the  pregnant  and  the  non-pregnant.  Abortion  is  favored  by  the  high 
temperature  and  cough  paroxysms.  The  relative  frequency  of  abortion  is  hard 
to  ascertain,  but  in  certain  small  series  of  cases  it  is  high  (3  out  of  4  times,  5  out 
of  7,  etc.).  Complications  of  measles  are  rare,  and  there  is  on  record  but  a 
single  case  of  death  from  bronchopneurnonia.  It  is  claimed  that  the  tendency 
to  post-partum  sepsis  and  hemorrhage  is  increased,  so  that  unusual  precautions 
should  be  taken  to  ward  off  these  accidents. 

4.  Typhoid  Fever. — The  severity  of  this  affection  in  pregnancy  is  neither 
necessarily  increased  nor  diminished.  Statistics  may  give  either  a  high  or  a  very 
low  mortality.  The  proportion  of  abortion  and  premature  delivery  is  high, 
ranging,  according  to  statistics,  from  58  to  83  per  cent.  As  a  rule,  all  depends  on 
the  gravity  of  the  case,  although  sometimes  pregnancy  will  not  be  interrupted 
even  in  the  most  severe  examples.  Toxemia  is  doubtless  the  chief  agent  in 
bringing  about  abortion.  Sepsis  is  said  to  be  a  common  sequel  of  labor  during 
typhoid  fever,  so  that  the  patient  becomes  a  victim  of  associate  infection  with 
two  formidable  maladies. 

5.  Typhus. — The  few  data  upon  record  do  not  admit  of  the  drawing  of 
any  conclusions  upon  the  course  of  the  disease  in  pregnancy  or  the  frequency  with 
which  abortion  is  produced. 

6.  Erysipelas. — There  is  neither  special  disposition  to  nor  immunity  from  this 
affection  in  pregnancy,  nor  is  its  course  modified  by  the  latter  condition.  Fatali- 
ties do  not  appear  to  have  been  recorded,  and  while  abortion  occurs  with  fre- 
quency, there  are  no  statistics  by  which  this  may  be  determined. 


SKIN   DISEASES.  337 

7.  Malaria. — There  is  less  than  the  normal  susceptibility  to  malarial  attacks. 
It  is  sometimes  developed  during  the  puerperium;  it  is,  however,  probable  that 
many  cases  reported  as  malarial  have  been  cases  of  unrecognized  sepsis.  When 
malarial  fever  occurs  in  pregnancy,  it  may  pursue  an  atypical  course;  abortion 
seldom  occurs.  The  fetus  may  suffer  from  this  disease,  being  born  with  evidence 
of  it;  e.  g.,  enlarged  spleen.  Quinin  should  be  administered,  as  in  the  non- 
pregnant state. 

8.  Pneumonia. — In  this  disease  the  prognosis  is  grave  in  late  pregnancy, 
owing  to  the  diminished  breathing  space,  the  hydraemia,  and  the  extra  work 
which  the  heart  has  to  perform.  Interruption  of  pregnancy  frequently  occurs. 
The  gravity  of  the  disease  and  the  tendency  to  miscarriage  increase  progres- 
sively during  pregnancy,  and  are  greatest  in  the  later  months.  All  the  symp- 
toms are  aggravated  by  labor,  hence  the  induction  of  labor  is  not  indicated. 
Premature  labor  or  abortion  should  be  prevented,  if  possible.  However,  if  labor 
begins,  it  should  be  hastened  within  safe  limits.  The  heart  should  be  sustained, 
and  the  same  general  treatment  be  pursued  as  in  the  non-pregnant  state;  cupping 
and  full  doses  of  strychnin  are  of  great  service. 

9.  Syphilis. — This  is  one  of  the  most  common  causes  of  abortion  (compare 
Placental  Syphilis  and  Abortion).  The  virulence  of  the  disease  proper,  however, 
does  not  seem  to  be  increased,  except  that  the  initial  lesion  is  apt  to  be  very 
severe,  owing,  perhaps,  to  the  genital  hyperemia  and  the  hypertrophy  incident 
to  pregnancy. 

The  prognosis  will  depend,  to  a  great  degree,  on  the  resistant  power  of  the 
patient,  as  well  as  on  the  septic  micro-organisms  which  are  associated  with  the 
micro-organisms  of  syphilis.  Fournier  has  said  that  "  a  syphilitic  woman  who 
becomes  pregnant  is  more  likely  to  abort  than  is  a  pregnant  woman  who 
becomes  syphilitic."  Treatment  should  begin  as  soon  as  the  infection  is  dis- 
covered, and  be  pushed  just  short  of  salivation,  being  in  general  the  same  as 
that  of  the  non-pregnant  state.  For  the  local  lesions,  antiseptic,  sedative, 
and  drying  powders  should  be  used.  Besides  medicinal  measures,  tonics  and 
systemic  nutritious  feeding  are  demanded.- 


XVII.  SKIN  DISEASES. 

/.  Pruritus.  2.  Pigmentation,  j.  Herpes  Gestationis,    4.  Impetigo  Herpetiformis.  5.  Alopecia. 

6.  Fibroma  M olluscum  Gravidarum. 

Besides  the  ordinary  affections  of  the  skin,  to  which  she  is  as  liable  as  the  non- 
pregnant, a  pregnant  woman  may  at  times  show  eruptions  which  are  intimately 
connected  with  her  state.  As  a  general  rule,  acne,  psoriasis,  and  eczema  are  very 
much  worse  during  the  pregnant  state.  Not  infrequently  it  happens  that  after 
its  termination  those  of  internal  origin,  eczema  and  psoriasis,  disappear  of  them- 
selves. The  exanthems  of  eruptive  fevers  are  not  modified  by  a  pregnancy  they 
complicate. 

I.  Pruritus. — Itching  is  a  symptom,  not  a  disease.  The  term  pruritus  is 
limited  in  its  use  to  conditions  in  which  there  are  no  evidences  on  the  skin  except 
those  which  result  from  scratching. 

When   the    diagnosis   of  pruritus    is    established,  it    remains  to  determine 

the    causative    factor.     Parasites,   pediculi,  and   the   itch   mite   must    first  be 

excluded.     Various    excitants,   such   as    jaundice,    intestinal    intoxication,  the 

toxemia  of  pregnancy  proper,  and  nephritis,  may  operate  in  pregnant  women. 
22 


338  PATHOLOGICAL  PREGNANCY. 

There  may  be  localized  pruritus  of  the  genitals  from  diabetes  or  leucorrhea; 
of  the  anal  region  from  rectal  ulcers  or  hemorrhoids.  In  this  climate  there  is  a 
pruritus  (pruritus  hiemalis)  which  comes  on  at  the  approach  of  winter,  affects 
chiefly  the  wrists  and  legs,  and  is  probably  due  to  feebleness  of  circulation.  After 
these  factors  are  excluded,  there  remains  a  pruritus  of  pregnancy.  Its  causation 
is  doubtful,  but  it  is  probably  due  to  irritation  of  the  peripheral  nerves  by  circu- 
lating toxins.  There  is  no  eruption  when  pruritus  begins,  but  when  the  patient 
is  seen,  secondary  ones  due  to  scratching  are  present.  They  are  blood-crusted 
excoriations,  generally  linear,  which  may  show  various  infections.  The  char- 
acter of  the  latter  are  impetiginous  or  ecthymatous  (see  page  339).  If  the 
disease  has  lasted  for  any  length  of  time,  the  skin  is  thickened,  pigmented, 
and  its  lines  are  deepened.  There  is  often  an  indolent  enlargement  of  the 
lymph-nodes.  In  all  cases  of  general  pruritus  pregnancy  toxemia  should  be 
suspected,  and  the  urine  examined  for  the  total  nitrogen  and  its  compounds. 

Treatment. — When  pruritus  is  local,  the  cause  should  be  removed  at  once.  In 
general  itching,  the  eliminative  functions  of  bowels,  skin,  and  kidneys  should  be 
stimulated.  (See  Toxemia  of  Pregnancy.)  Copious  draughts  of  water  are  recom- 
mended as  a  routine  measure.  Internally,  the  opium  derivatives  are  not  to  be 
thought  of.  The  patient  usually  demands  relief  at  once,  so  local  measures  are  of 
first  importance.  Practically  all  anti-parasitics  are  antipruritics — sulphur,  naph- 
thol,  salol,  menthol,  thymol,  camphor,  and  carbolic  acid.  They  are  used  in  lotion, . 
alcoholic  or  watery,  if  the  skin  is  not  dry;  if  it  is,  ointments  are  preferable. 
It  is  better  to  use  the  latter  in  any  case  until  pus  infection  disappears.  In  local 
pruritus,  cleanliness  is  a  necessity.  Pledgets  soaked  in  carbolic  acid  or  Labar- 
raque's  solution  may  be  placed  between  the  labia  or  in  the  anus.  Silver  nitrate 
(5  to  10  per  cent,  solution)  painted  over  the  parts  is  helpful.  Antipruritics, 
as  a  rule,  are  best  combined  with  diachylon  ointment. 

2.  Pigmentation. — The  specific  pigmentation  of  pregnancy  has  sites  of  elec- 
tion— the  face  and  chest,  especially  the  breasts.  Pigmentation  of  the  areola  and 
nipple  can  hardly  be  regarded  as  pathological.  Clinically,  the  color  varies  from  a 
golden  yellow  to  a  dark  brown.  The  spots  vary  in  size  up  to  a  universal  involve- 
ment. They  are  formed  by  coalescence  or  peripheral  extension.  The  borders  are 
sharply  defined  and  rounded.  Involution  begins,  as  a  rule,  in  the  oldest  por- 
tions. There  is  no  disease  for  which  pigmentation  may  be  mistaken  except 
tinea  versicolor.  In  the  latter  affection  the  scales  may  be  readily  scraped  off, 
and  always  show  threads  and  spores  of  its  fungus.  Metabolic  pigmentation 
of  any  origin  is  pretty  difficult  to  remove.  That  of  pregnancy  has  more  ten- 
dency to  disappear  spontaneously  than  is  the  case  in  other  states,  and  when 
it  occasions  no  distress  to  the  patient's  mind,  it  is  qtiite  as  well  to  let  it  alone. 
If  it  is  disfiguring,  its  involution  can  be  hastened  on  unexposed  parts  by  strong 
exfoliative  applications,  such  as  a  20  per  cent,  resorcin  ointment  or  a  10  per 
cent,  salicylic  acid  collodion  or  plaster.  The  inflammation  set  up  has  a  distinct 
effect  in  promoting  absorption.  On  the  face,  these  things  are  likely  to  do 
more  harm  than  good.  Peroxide  of  hydrogen  or  pyrozone  (the  weaker  solution) 
has  sometimes  a  good  effect.  It  must  be  applied  five  or  six  times  a  day.  A 
favorite  formula  is  bismuth  suboxid,  ammoniated  mercury,  aa  ,5j;  lanolin,  5j. 
The  application  is  to  be  stopped  temporarily  when  scaling  appears. 

3.  Herpes  Gestationis  {Dennatitis  Herpetiformis). — Its  lesions  have  nothing 
distinctive  about  them.  They  consist  of  erythematous  patches,  not  of  great  ex- 
tent, sharply  defined,  without  scales  or  infiltration;  of  papules  which  are  tiny  and 
pale,  capped  with  blood  crusts,  like  those  of  prurigo,  or  larger  elements,  red, 
pointed,  and  hard.     On  the  patches  of  erythema  or  on  the  papules,  vesicles  may 


SKIN  DISEASES. 


339 


appear  which  can  be  found  on  parts  not  readily  reached  by  the  nails.  Lastly, 
bullae  may  arise  on  a  reddened  base.  The  sites  of  predilection  are  the  buttocks, 
backs  of  the  thighs,  flanks,  and  forearms,  but  in  exceptional  cases  the  eruption 
may  spread  over  the  whole  surface.  The  mucous  membranes  are  never  attacked. 
The  lesions  all  have  a  tendency  to  herpetiform  grouping  in  clusters  without 
coalescence,  itch  furiously,  appear  in  successive  crops,  and  leave  deep  pigmen- 
tation. The  patient  may  get  into  a  bad  nervous  condition  with  insomnia  from 
the  irritation. 

The  disease  is  due  to  faulty  metabolism  or  toxemia.  It  follows  shock  and 
depressing  conditions  generally.     It  is  a  very  rare  complication  of  pregnancy. 

Treatment. — Termination   of  pregnancy   generally,    but  not   always,  brings 
an  attack  to  a  close.     There  are  three  things  which  are  useful  in  the  treatment 
of  dermatitis  herpetiformis.     The  first  is  rest,  the  second  is  arsenic,  and  the 
third  is  sulphur.     Prognosis  is  good 
as  regards  life,  bad  as  to  recurrence. 

4.  Impetigo  Herpetiformis. — It 
was  formerly  thought  that  this  dis- 
ease appeared  only  in  pregnant 
women,  but  cases  have  occurred  in 
the  non-pregnant  and  in  males. 
There  appear  about  the  ano-genital 
region,  the  umbilicus,  axillae,  and  in- 
side of  the  thighs,  groups  of  pustules 
which  spread  peripherally  until  a 
large  part  of  the  surface  is  covered. 
The  mucous  membranes  are  affected 
in  the  same  way  as  is  the  skin.  The 
disease  may  terminate  with  preg- 
nancy, but  usually  it  does  not.  The 
cases  reported  have  all  terminated 
fatally  except  two,  either  from  an 
intercurrent  pulmonary  affection  or 
in  a  typhoid  state.  Internal  medi- 
cation is  useless  except  in  the  form 
of  tonics  and  maintenance  of  nutri- 
tion. 

5.  Alopecia. — Loss  of  hair  is  not 
a  common  phenomenon  in  the  preg- 
nant state  or  immediately  following 
it.  Of  the  two  periods,  it  is  oftener  developed  post  partum  than  in  the  course 
of  pregnancy.  There  is  a  possibility,  however,  that  the  fall  is  noticed  only  when 
the  hair  has  become  thin.  The  fall  is  general,  but  the  temporal  regions  are 
usually  chiefly  affected.     It  is  rare  that  any  part  is  completely  denuded. 

It  would  seem  probable  that  this  affection  is  to  be  classed  with  the  alopecias 
of  prolonged  fevers.  If  so,  it  is  a  nutritional  disturbance  in  the  hair  papillae, 
doubtless  toxemic  in  origin. 

Treatment. — The  women  usually  require  iron  and  strychnin,  hydrotherapy 
and  forced  feeding.  Locally,  something  can  be  done  in  the  way  of  prevention 
by  careful  attention  to  the  scalp  hygiene  during  pregnancy.  Shampooing 
with  tincture  of  green  soap  every  fortnight  and  application  of  a  5  per  cent, 
resorcin  lotion  are  sufficient.  After  full  development,  as  regards  the  shampoo, 
it  is  well  to  warn  the  patient  that  she  may  see  a  considerable  loss  at  first.     I 


Fig.  473. — Fibroma  Molluscu.m  Gravidarum. 


340  PATHOLOGICAL  PREGNANCY. 

there  is  any  scaling,  the  resorcin  lotion  should  be  used  two  or  three  times  a 
week.  A  serviceable  wash  is  salicylic  acid  gr.  xx,  resorcin  one-half  drachm, 
oleum  ricini  one-half  drachm,  oleum  lavandulse  ten  drops,  alcohol  one  ounce. 
When  there  is  no  dandruff,  pilocarpin  is  incomparably  the  best  remedy.  It 
cannot  very  well  be  used  in  injection  on  account  of  its  depressant  action,  but  it 
may  be  applied  to  the  scalp  every  day  in  a  one  or  two  per  cent,  alcoholic  lotion. 
The  hair  should  be  parted  and  the  wash  well  rubbed  into  the  roots.  If  the  ex- 
pense is  too  great,  undiluted  fluid  extract  of  jaborandi  may  be  substituted, 
but  is  not  nearly  so  efficacious.     Prognosis  is  always  good. 

6.  Fibroma  Molluscum  Gravidarum. — Under  the  name  of  fibroma  molluscum 
gravidarum,  Brickner  *  has  described  a  hyperplastic  process  which  differs  from 
the  ordinary  condition  recognized  by  the  same  name  only  in  its  connection  with 
pregnancy.  The  growths  begin  to  appear  about  the  fourth  to  the  sixth  month 
in  the  form  of  a  number  of  small  sessile  or  pedunculated  elevations  about  the 
neck,  breasts,  and  submammary  region  (Fig.  473)-  They  may  increase  slowly 
in  number  and  become  pigmented  to  a  degree  varying  with  individuals.  As  a 
rule,  they  are  smooth,  soft,  and  polypoid  in  appearance,  but  owing  to  secondary 
growths  may  digitate,  or  if  the  subdivision  is  less  marked,  show  a  mulberry- 
appearance.  The  pigment  is  melanin,  a  non-ferruginous,  metabolic  material 
deposited  in  the  lowermost  layers  of  the  epidermis  chiefly.  Histologically,  the 
growths  consist  of  an  increase  of  a  rather  acellular  collagen,  accompanied  by  a 
corresponding  hyperplasia  of  the  prickle-cells.  Treatment  is  unnecessary,  as 
the  fibromas  di;  appear  spontaneously  post-partum  when  other  regenerative 
processes  are  complete. 


XVIII.  DISEASES  OF -THE  OSSEOUS  SYSTEM. 

/.  Relaxation  of  the  Pelvic  Joints.      2.  Inflammation  of  the  Pelvic  Joints.      j.  Osteomalacia. 

4.  Rachitis. 

1.  Relaxation  of  the  pelvic  joints  is  an  exaggerated  degree  of  the  normal 
process  by  which  the  pelvis  is  prepared  for  labor  (see  page  114).  On  the  other 
hand,  it  may  be  caused  by  a  pathological  state  of  the  joints,  such  as  inflammation. 
The  sequelae  of  this  condition  may  be  suppuration,  fluid  in  the  joints,  and  other 
abnormal  conditions.  Locomotion  may  be  effectually  hindered,  and  as  a  rule 
there  are  pains  in  these  joints,  as  well  as  in  the  thighs  and  in  the  lumbar  region. 
A  firm  binder  gives  great  relief  and  is  often  a  sufficient  support  for  comfortable 
locomotion  (Figs.  228  and  229).  Rest  in  bed  must  occasionally  be  enjoined; 
the  binder  should  be  worn  after  delivery  until  the  parts  have  returned  to  their 
normal  condition.  I  am  accustomed  to  make  use  of  the  same  type  of  binder  in 
these  cases  as  after  the  early  days  of  the  puerperium  (Part  .VI);  a  plaster-of- 
Paris  bandage  is,  perhaps,  necessary  in  the  more  severe  cases. 

2.  Inflammation  of  the  Pelvic  Joints. — In  rare  instances  an  inflammatory 
process  occurs  in  connection  with  the  relaxation  just  mentioned.  The  symp- 
toms are  aggravated,  the  pain  may  be  severe,  and  there  is  swelling  over  the 
affected  joints,  with  tenderness  on  pressure.  The  treatment  is  the  same  as  for 
simple  relaxation,  with  the  addition  of  anodynes  and  anodyne  applications. 
Cold  applications  may  be  of  service. 

3.  Osteomalacia. — This  affection  is  rare  in  America,  but  endemic  in  Italy,. 

*•' American  Journal  Obstetrics,"  vol.  Liii,  No.  2.  1906. 


DISEASES  OF   THE  OSSEOUS  SYSTEM.  341 

Austria,  Switzerland,  and  other  portions  of  Europe.  The  subjoined  account 
is  taken  largely  from  Schuchardt's  *  work  on  diseases  of  the  bones  and  joints. 

The  affected  bones  are  of  a  lively  red  hue,  and  are  either  soft  and  flexible 
or  show  a  high  degree  of  porotic  atrophy,  a  saw  cutting  through  them  as  if 
they  were  rotten  wood.  In  the  very  highest  degree  the  periosteum  is  trans- 
formed into  a  sac  containing  a  white,  puffy  mass  which  represents  the  original 
osseous  tissue.  As  a  rule,  the  marrow  is  unusually  reddened,  and  commonly 
consists  of  lymph-marrow;  in  rare  instances  fat-marrow  may  be  present,  the 
color  then  being  yellow.  Cystic  degeneration  often  occurs,  and  is  thought  to 
be  salutary  and  to  denote  the  resolution  of  the  morbid  process. 

The  naked-eye  deformities  in  osteomalacia  are  numerous  and  characteristic. 
At  first,  while  the  patient  is  able  to  walk  about,  the  changes  are  those  produced 
by  the  weight  of  the  body.  There  is  a  stronger  bend  to  the  neck  of  the  femur. 
The  pelvis  takes  on  the  characteristic  clover-leaf  form,  the  pubic  bone  becomes 
beak-like,  the  sacrum  is  bent  toward  the  pelvic  axis,  the  lumbar  vertebrae  are 
shortened  and  compressed  and  biconcave,  suggesting  the  vertebrae  of  fish,  etc. 
The  base  of  the  skull  is  elevated.  The  origins  of  large  muscles,  tendons,  and 
ligaments  often  become  unduly  prominent  because  of  the  softness  of  the  bones 
(osteomalacic  enlargement  of  bones). 

The  long  bones  are,  at  the  outset,  almost  non-participating,  but  eventually 
exhibit  flexure  and  curvature.  In  the  worst  cases  these  bones  become  simply 
amorphous  masses  of  flesh. 

If  recovery  sets  in  in  these  cases,  new  osseous  tissue  is  formed,  the  centers 
of  the  bones  being  occupied  by  osseous  tubercula  or  enostoses. 

With  regard  to  the  course  pursued  by  puerperal  osteomalacia,  the  disease 
seldom  attacks  women  who  live  under  hygienic  requirements.  Miserable, 
overworked,  and  underfed  peasants,  living  in  damp  and  unhealthful  surround- 
ings, are  the  principal  victims.  Even  here  certain  endemic  influences  obtain, 
so  that  Italy  and  Switzerland  take  the  lead  over  other  countries  in  morbidity. 

As  a  rule,  multigravidse  are  attacked  by  preference.  The  pelvic  bones 
are  first  affected,  and  under  the  influence  of  the  warmth  of  the  bed,  rheumatoid 
pains  set  in.  Tenderness  over  one  or  both  ischial  tuberosities  is  an  early  symp- 
tom, interfering  with  sitting.  The  pains  appear  wherever  softening  is  in  prog- 
ress. The  patient  loses  rapidly  in  height,  even  to  the  extent  of  a  foot  or  more. 
The  joints  appear  to  be  involved  in  a  sort  of  arthritis  deformans,  and  fever 
is  occasionally  present.  Changes  in  the  muscles,  not  unlike  those  of  progres- 
sive muscular  atrophy,  often  occur.  A  peculiarity  of  gait  is  thought  to  be  due 
to  paresis  of  the  ileopsoas  muscle.  Later  on  it  is  found  impossible  to  abduct 
the  thigh  and  eventually,  of  course,  all  locomotive  efforts  become  impossible. 
The  condition  may  last  for  years,  with  exacerbations  and  remissions.  Par- 
ticular deformities  may  result  from  various  positions  assumed  while  the  patient 
is  bed-ridden.  In  diagnosis  this  affection  has  not  infrequently  been  confounded 
with  various  diseases  of  the  spinal  cord.  Symptoms  of  great  value  in  early 
diagnosis  are  isolated  iliopsoas  paresis,  the  diminution  in  height,  and  the  altera- 
tion in  the  measurement  of  the  conjugate.  With  regard  to  treatment  and  prog- 
nosis, Winckel  has  seen  spontaneous  recovery.  Tonic  and  hygienic  measures 
of  all  sorts  are  prescribed,  and  prolonged  treatment  with  phosphorus  appears 
to  give  excellent  results.  Cod-liver  oil  is  usually  given  as  a  synergist.  The  fact 
that  the  pelvic  bones  have  undergone  softening  and  extensibility,  despite  the 
pelvic  narrowing,  does  not  favor  the  expulsion  of  the  child.  According  to  Litz- 
mann,  there  occurred  in  72  osteomalacic  women  only  21  natural  labors.  In  16 
*  In  vol.  XXVIII  of  the  "Deutsche  Chirurgie." 


342  PATHOLOGICAL  PREGNANCY. 

cases  the  fetal  head  was  perforated;  in  40,  Caesarean  section  was  performed, 
artificial  premature  delivery  was  the  management  in  2  cases  and  symphyseotomy 
in  one.  Seven  women  had  rupture  of  the  uterus,  and  four  died  undelivered. 
Porro  employed  his  utero-ovarian  amputation  in  these  cases  with  much  success. 
Fochier,  of  Lyons,  and  Levy,  of  Copenhagen,  who  have  done  many  Porro  opera- 
tions in  osteomalacic  labors,  came  to  the  conclusion  that  the  castration  incidental 
to  this  form  of  intervention  has  a  salutary  effect  upon  the  disease.  In  1886 
Fehling  began  to  test  this  theory  by  the  performance  of  simple  castration  in 
these  cases,  with  an  astonishing  degree  of  success,  and  the  practice  has  become 
general.  Even  after  the  first  day  from  the  time  of  operation  the  pains  abate  and 
the  tenderness  becomes  less  marked.  In  a  small  number  of  cases  no  benefit  is 
received  from  the  operation,  which  should  not  be  performed  until  all  other 
measures  have  failed.  (See  Section  on  Osteomalacic  Pelvis,  Part  V.) 
4.  Rachitis. — (See  Pelvic  Deformity,  Part  V.) 


XIX.    THE    PREMATURE    INTERRUPTION    OF  PREGNANCY; 

ABORTION;    IMMATURE  LABOR  OR  MISCARRIAGE; 

PREMATURE  LABOR. 

Classification  and  Definitions. — An  abortion  is  a  termination  of  pregnancy 
before  the  placenta  is  formed;  namely,  in  the  first  twelve  weeks  or  three  months. 
A  miscarriage,  or  "partus  immaturus,"  is  the  termination  of  gestation  at  any 
time  from  the  end  of  the  twelfth  week,  or  third  month,  to  the  end  of  the  twenty- 
seventh  week,  or  six  and  three-fourths  lunar  months.  A  premature  labor,  or 
''partus  prematurus,"  is  the  premature  interruption  of  pregnancy,  occurring 
at  and  after  the  twenty-eighth  week,  or  seventh  lunar  month,  and  before  the 
thirty-eighth  week,  or  nine  and  a  half  lunar  months.  I  look  upon  the  classi- 
fication which  groups  under  the  term  abortion  all  cases  occurring  within  the 
first  twenty-seven  weeks  of  gestation  as  also  justifiable,  because  before  this 
time  practically  no  regard  need  be  paid  to  the  life  of  the  fetus,  which  may 
be  regarded  as  lost.  I  would,  then,  speak  of  early  abortions  in  the  first 
twelve  weeks,  and  late  abortions  from  the  end  of  the  twelfth  week  to  the  end 
of  twenty-seven  and  a  half  weeks.  Most  of  the  German  text-books  on  ob- 
stetrics look  upon  the  separation  of  abortion  and  immature  labor  as  unjustifiable^ 
and  consider  the  period  of  viability,  at  the  end  of  the  seventh  month,  to  be  the 
only  admissible  point  of  division.  Most  of  the  French  text -books  understand 
the  term  "avortement"  to  extend  to  the  end  of  the  seventh  lunar  month  of 
gestation.  According  to  this  classification,  abortions  are  pregnancies  ter- 
minated in  the  first  six  and  three-fourths  months,  or  the  first  twenty-seven 
weeks;  a  further  division  is  made  into  early  abortions  in  the  first  twelve 
weeks,  and  late  abortions,  falling  within  the  period  from  the  beginning  of 
the  fourth  to  the  end  of  the  seventh  lunar  month;  the  term  premature  labor 
covers  the  remaining  cases  from  the  twenty-eighth  to  the  thirty-eighth  week. 
For  fear  of  confusion  of  terms  already  generally  accepted  in  this  country,  I 
hesitate  to  adopt  this  latter  classification  here.  The  period  of  viabiUty  is  the 
time  when  the  fetus  can  live  apart  from  its  mother,  the  turning-point  between 
partus  immaturus  and  prematurus ;  and  this  limit  is  generally  placed  at  the 
end  of  the  seventh  lunar  month,  or  twenty-eighth  week,  from  conception. 
We  must  not  lose  sight  of  the  facts,  however,  that,  on  the  one  hand,  fetuses 
may  not  be  viable  until  after  this  estimated  date,  because  the  calculation  of 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR. 


343 


the  duration  of  pregnancy  is  uncertain;  and,  on  the  other  hand,  that,  excep- 
tionally, children  bom  previous  to  the  calculated  twenty-eighth  week  may 
live.  There  is  to-day  no_  doubt  *  that  many  children  born  before  the  end 
of  the  seventh  lunar  month  may  be  saved  by  the  use  of  the  couveuse  and  of 
gavage,  and  that  a  certain  proportion  of  the  children  bom  at  the  twenty-seventh, 
twenty-sixth,  twenty-fifth,  or  even  twenty-fourth  week  of  gestation  can  be 
preserved.     Budin  claims  to  have  saved  30  per  cent,  at  the  twenty-fourth  week. 

A  complete  abortion  is  one  in  which  the 
fetus  and  membranes  are  cast  off  intact ; 
an  incomplete  abortion  is  one  in  which  the 
fetus  is  born,  and  the  embryonic  mem- 


FiG.  474.— First  Type  of  Abortion. 
Retention  of  remnants  of  decidua  only. 
So-called  "complete  abortion." 


Chorion. 
Amnion. 
Liquor  amiiii. 
Embryo. 


Fig.  475. — Second  Type  of  Abortion. 
Retention  of  deciduae.  Incomplete  abor- 
tion. 


branes,  all  or  in  part,  remain  in  the  uterus;  an  abortion  is  inevitable  when  such 
hemorrhage  occurs,  and  the  ovum  descends  into  the  lower  part  of  the  uterus,  or 
when  part  of  the  chorion  or  liquor  amnii  escapes ;  a  concealed  abortion  is  one  in 
which  the  embryo  perishes,  but  is  not  expelled;  in  missed  abortion  the  embryo 
dies,  symptoms  of  threatened  abortion  occur  and  subside,  and  the  ovum  remains 
in  the  uterus  for  a  varying  length  of  time;  spontaneoiis  abortions  are  those  which 
occur  naturally,  not  being  caused  by  artificial  interference  of  any  kind;  indticed 
abortion  is  one  which  is  caused  intentionally  and  artificially,  for  strictly  medical 
*Ahlfeld:  "Arch.  f.  Gynak.,"  viii,  p.  194. 


344 


PATHOLOGICAL  PREGNANCY. 


reasons;  criminal  abortion, "or  feticide,  signifies  the  act  of  attempting  to  procure 
an  emptying  of  the  uterus  for  other  than  strictly  medical  reasons,  and  the  term 
holds  good,  whether  the  attempt  proves  successful  or  fails.  The  terms  slow  and 
retarded  abortions  explain  themselves.  Therapeutic  abortion  is  one  which  is  per- 
formed for  strictly  medical  reasons. 

Pathology. — The  Ovum:  In  only  exceptional  instances  does  the  entire  ovum 
intact,  with  the  vera,  pass  out  in  the  first  months.  One  can  repeatedly,  in  curet- 
ting cases  of  apparently  complete  abortion,  obtain  pieces  of  tissue  which  the 
microscope  proves  to  be  decidua  (Fig.  52).     It  is  common  for  the  refiexa  to  be 


Placenla. 


SeroHna, 


Cord.  ■  V.  I 


Amnion. 
Liguor  amnii. 
Embryo, 


Fig.  476. — Third  Type  of  Abortion. 
Retention  of  deciduse  and  chorion. 
Incomplete  abortion. 


Fig.  477. — Fourth  Type  of  Abortion. 
Retention  of  deciduse,  chorion,  rudi- 
mentary placenta  and  amnion.  In- 
complete abortion. 


ruptured  by  the  descent  of  the  ovum,  leaving  the  former,  with  the  vera  and  sero- 
tina,  to  pass  away  during  the  puerperium,  or  to  be  removed  by  operation.  Again, 
we  infrequently  see  the  chorion  as  well  as  the  reflexa  ruptured,  the  cord  being 
torn  from  the  placenta,  and  the  fetus,  enclosed  in  the  amnion,  with  hquor 
amnii,  alone  expelled  (Fig.  106).  I  have  several  specimens  of  this  variety  of  abor- 
tion, and  it  has  been  observed  as  late  as  the  sixteenth  week  (Fig.  106).  A  rare 
modification  of  this  last  process  is  shown  when  decidua  vera,  reflexa,  and  chorion 
are  torn  away,  leaving  the  placenta  (serotina)  fitted  like  a  cap  on  the  amnion 
(Fig.  478).     The  further  gestation  has  advanced  bevond  the  twelfth  week,  the 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR. 


345 


more  closely  does  the  interrupted  pregnancy  resemble  labor  at  term.  Moles: 
In  many  cases  the  embryo  dies  early,  but  abortion  does  not  occur  at  once;  the 
result  is  a  uterine  mole.  This  formation  consists  of  a  sac  with  thick  walls  which 
are  at  first  red,  but  which  later  become  of  a  lighter  hue  (Fig.  479).  The  cavity 
is  irregular  and  corresponds  to  the  amnion;  the  entire  space  between  the  amnion 
and  the  external  surface  is  bound  by  chorion  within  and  decidua  without, 
and  is  filled  with  blood,  thus  forming  "blood  moles"  and  "flesh  moles" 
(Fig.  479).  In  many  cases  the  fetus  entirely  disappears.  If  the  fetus  has  not 
disappeared,  it  may  retain  a  fresh  appearance,  despite  the  fact  that  it  may 
have  been  dead  many  days;  or  maceration  may  take  place,  the  mass  becom- 
ing soft,  flabby,  and  dark  red;  the  fetal  surface  is  covered  with  blebs;  all  the 
parenchymatous  organs  degenerate;  the  brain  is  fluid  and  the  skull  collapses. 
Such  fetuses  are  not  infected,  and  are  sometimes  spoken  of  as  jcetus  sangui- 
nolentus.  In  other  cases  the  fetus  becomes  dry  or  mummified,  and  may  remain 
in  the  uterus  for  years  (Figs.  444  and 
445).  In  rare  cases  a  second  preg- 
nancy may  take  place;  in  other  in-  ■  '•\^it^l^'' 
stances  the  mummified  fetus  becomes 


Fig.  47S. — Incomplete  Miscarriage  at 
THE  Fifteenth  Week.  The  amnion, 
covered  by  shreds  of  chorion  and  deci- 
dua, was  expelled  unruptured.  Most  of 
the  chorion  and  decidua,  and  the  entire 
placenta,  were  retained  in  the  uterine 
cavity.  (|  natural  size). — (Author's 
case.) 


Fig.  479. — Blood  Mole  Changing  into  a 
Flesh  Mole,  w,  White  area  in  the  blood 
mass;  b,  blood  extravasation  into  rudi- 
mentary placenta;  rs,  outer  rough  surface 
of  mole;  o,  ovum  cavity  with  amnion  cut 
open. — (Bumm.) 


calcified,  and  is  then  termed  fcetus  lithopcedion  (Fig.  446).  Periovular  Hemorrhage; 
Placental  Apoplexy  :  Up  to  the  end  of  the  second  month  there  is  a  marked  ten- 
dency for  the  blood  to  spread  out  and  form  a  thin  layer  ^  to  li  inches  (4  to 
30  mm.)  in  thickness,  upon  the  surface  of  the  chorion,  causing  the  ovum  to  re- 
semble a  piece  of  flesh,  bluish  or  blackish  in  color.  The  enveloping  mem- 
branes are  seldom  ruptured,  and  since  this  collection  of  blood  is  often  larger 
than  the  ovum  itself,  it  goes  to  show  that  the  ovum  is  not  the  source  of  this 
hemorrhage.  But  later,  in  the  third  and  fourth  months,  this  tendency 
decreases,  and  the  blood  is  apt  to  collect  in  a  limited  space  in  the  placenta, 
forming  placental  apoplexies.  This  latter  tendency  increases  with  the  advance 
of   pregnancy  (Figs.  482  and  483). 

Frequency. — For  many  reasons  exact  figures  as  to  the  frequency  of  pre- 
maturely interrupted  pregnancies  are  difficult  to  obtain.  During  the  first 
eight  weeks,  undoubtedly,  many  interruptions  of  pregnancy  pass  unnoticed, 
and  later  in  pregnancy  very  few  such  patients  enter  maternities,  and  many  do  not 


346 


PATHOLOGICAL  PREGNANCY. 


come  to  the  notice  of  private  physicians  or  of  dispensary  hospital  services. 
I  have  recently  made  an  exhaustive  study  of  the  premature  interruption 
of  pregnancy  occurring  among  ten  thousand  cases  of  labor  treated  in  a  dispen- 
sary or  outdoor  service,  in  New  York  city.  In  favor  of  a  greater  accuracy 
of  these  statistics  is  the  fact  that  all  of  the  635  cases  of  interrupted  pregnancy 
were  outdoor  or  dispensary  cases,  and  patients  under  such  circumstances  are 
more  likely  to  seek  aid  under  their  own  roof  than  to  apply  for  admission  to  a 
general  or  maternity  hospital.  Among  10,000  cases  of  labor  I  found  635  pre- 
mature interruptions;    namely,  242   abortions,   175    miscarriages    or  immature 


Fig.  480. — Abortion  at  the  Eighth 
Week.  Separation  of  the  (dv)  decidua 
vera  and  (5)  serotina  from  the  uterine 
wall.  Partial  descent  of  the  entire 
ovum;  hemorrhage  into  the  decidua  re- 
flexa;  beginning  dilatation  of  the  (i)  in- 
ternal OS.  e,  External  os;  lo,  lower  end 
of  ovum. 


Fig.  481. — Abortion  at  the  Eighth 
Week.  The  ovum,  entirely  separated 
from  the  uterine  wall,  rests  in  the  dilated 
cervical  canal,  the  (e)  external  os  alone 
preventing  its  escape  into  the  vagina  (v) 
— so-called  "cervical  abortion."  u, 
Uterine  cavity;  1,  internal  os;  r,  rudi- 
mentary placenta;  dr,  decidua  reflexa; 
d,  decidua  vera;  e,  external  os;t;,  vagina; 
i,  internal  os. 


labors,  and  218  premature  labors.  The  relative  frequency,  therefore,  was  one 
abortion  in  every  41.3  labors;  one  miscarriage  or  immature  labor  in  every  57,1 
labors;  and  one  premature  labor  in  every  45,8  labors.  In  other  words,  there  was 
either  an  abortion,  a  miscarriage,  or  a  premature  labor  once  in  every  15.7  labors. 
Age  of  Patients. — In  making  out  the  percentages  of  the  frequency  of  inter- 
rupted pregnancy,  in  different  five-year  groups  or  ages,  I  obtained  the  following 
results,  namely:  nineteen  years  and  under,  the  percentage  of  interruption  was 
3,52  per  cent.;  twenty  to  twenty-four  years,  5.01  per  cent.;  twenty-five  to 
twenty-nine  years,  6.02  per  cent.;  thirty  to  thirty-four  years,  7.33  per  cent.; 
thirty-five  to  thirty-nine  years,  10.48  per  cent.;  forty  to  forty-four  years,  18.94 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR. 


347 


per  cent.  From  these  studies  I  draw  the  conclusion  that  the  smallest  probability 
of  an  untimely  interruption,  of  pregnancy  is  before  the  twenty-fifth  year,  and  that 
the  greatest  probability  is  after  the  fortieth  year. 

Parity. — In  the  table  on  page  348  has  been  arranged  the  relative  frequency  of 
cases  according  to  the  number  of  preceding  labors  (-para),  added  to  the  number 
of  mature  labors,  under  primiparae,  pluriparae  (pluriparas  II,  III,  IV,  and  Vparae), 
and  multiparae. 

The  table  shows  that  in  primigravidae,  gestation  is  least  endangered  in  the  first 
months  of  pregnancy,  and  that  the  frequency  of  interruption  in  primigravidae  in- 
creases with  the  further  advance  of  pregnancy.     The  table  also  shows  that  in 


Fig.  482. — Abortion  at  the  Twelfth 
Week.  First  stage.  Beginning  separa- 
tion of  the  placenta  and  dilatation  of  the 
cervix,  d,  Decidua  vera;  w,  uterine  cav- 
ity; dc,  dilated  upper  portion  of  cervix; 
e,  external  os;  p,  attached  portion  of 
placenta;  ds,  decidua  serotina;  ps,  area 
of  placental  separation;  o,  cavity  of 
ovum;  i,  internal  os;  r,  origin  of  reflexa. 


Fig.  483. — Abortion  at  the  Twelfth 
Week.  Second  stage,  p.  Separation 
of  the  placenta  except  at  its  upper  por- 
tion; b,  beginning  separation  of  the  de- 
cidua vera,  cervix  dilated  and  contains 
the  lower  pole  of  the  ovum;  u,  uterine 
cavity;  c,  cavity  of  ovum;  a,  attached 
portion  of  placenta;  i,  internal  os;  br, 
blood-injected  reflexa;  e,  external  os. 


pluriparse  and  multiparas  the  relation  is  reversed;  the  majority  of  interruptions 
among  these  occurring  in  the  first  months  of  pregnancy,  and  that  the  frequency 
of  interruption  now  decreases  with  the  further  advance  of  gestation.  The  greater 
frequency  of  uterine  disease  in  multiparae,  and  the  large  number  of  preceding 
labors,  some  of  them  undoubtedly  anomalous,  are  a  sufficient  explanation  of  the 
greater  frequency  of  abortion  than  of  premature  labor  in  multiparas.  With  every 
additional  interruption  of  pregnancy  the  length  of  gestation  recedes,  so  that  after 
the  occurrence  of  a  premature  labor  there  ensue  first  miscarriages  and  finally 
abortions.  The  uterus,  therefore,  in  the  presence  of  uterine  disease,  becomes  ever 
less  tolerant  of  subsequent  pregnancies,  and  expels  its  contents  earlier,  in  pro- 
portion to  the  number  of  preceding  interruptions  of  pregnancy,  thus  emphasiz- 
ing Winckel's  statement  that  "  the  longer  existence  of  uterine  disease  leads  to 
ever  earlier  interruption  of  pregnancy." 


348 


PATHOLOGICAL   PREGNANCY. 
.■'       TABLE  OF  PARA. 


Primiparae   2q 

Pluriparas* 120 

Multi|)aras 79 

Unknown 14 

Total 242 


Mis- 
carriages. 

Prhmature 
Labors. 

terrupted 
Pregnan- 
cies. 

Total  Full 
Term. 

TERRUPTED 

AND  Full 
Term. 

22 
94 
49 

10 

71 

97 

46 

4 

122 

311 

174 
28 

2,009 
5,202 

2,047 
107 

2,131 
5.513 
2,221 

135 

175 

i        218  ■ 

1 

635 

9.36s 

10,000 

Month  of  Gestation. — I  found  in  the  635  cases,  as  will  be  seen  in  the  table 
on  page  348,  that  there  is  a  marked  tendency  for  gestation  to  terminate  in  the 

third  month,  23.91  per  cent,  occurring  at 
that  time;  in  the  fourth  month,  11. 18 
per  ceiit.;  in  the  fifth  month,' 6.93  per 
cent. ;  in  the  sixth  month  only  the  slight 
liability  of  6.15  per  cent.;  a  slight  in- 
crease in  the  seventh  month  to  9.60  per 
cent. ;  and  in  the  eighth  and  ninth 
months  the  frequency  again  goes  up  to 
12.63  psr  cent,  and  12.25  per  cent,  re- 
spectively. 

Etiology. — The  causes  of  interrupted 
pregnancy  may  be  placed  in  three 
classes,  and  named  in  the  order  of  their 
frequency  (i)  maternal  causes;  (2)causes 
in  the  ovum,  embryo,  and  fetus;  (3) 
paternal  causes. 

I.  The  maternal  causes  are  divisible 
into  the  systemic  and  the  local.  The 
systemic  causes  include  obesity,  mar- 
riages of  consanguinity,  pregnancies  in 
rapid  succession,  very  hot  climates,  and 
very  high  altitudes.  Poisons,  such  as 
syphilis,  which  holds  the  first  place,  are  a 
frequent  cause;  e.g.,  malaria;  large  doses 
of  arsenic  in  skin  diseases ;  lead  and  mer- 
cury in  factories;  the  abuse  of  drugs 
known  as  oxytocics  (ergot,  cottonroot, 
quinin,  aloes,  juniper,  black  hellebore, 
tansy,  pennyroyal,  cantharides,  any  of 
these  rarely  disturb  a  healthy  ovum  in  a 
healthy  uterus) ;  and  the  toxemia  of  kid- 
ney insufficiency.  The  effects  of  mater- 
nal toxemia  on  the  fetus  depend  not  on 
the  intensity  of  the  poison,  but  on  the 
power  it  has  to  excite  uterine  irritability. 
In  some  cases  this  irritability  is  so  easily 
aroused  that  a  slight  degree  of  toxemia 
will  be  sufficient  to  excite  it,  entailing  the 
expulsion  of  the  fetus  before  sufficient  time  has  elapsed  for  it  to  perish  from 

*  Pluriparae  in  II,  III,  IV,  Vpars. 


Fig.  484. — Abortion  at  the  Twelfth 
Week.  Third  stage.  The  ovum,  sepa- 
rated and  expelled  from  the  uterine 
cavity  (uc),  lies  partly  in  the  cervical 
canal  and  partly  in  the  upper  third  of 
the  vagina.  A  portion  of  the  decidua 
vera  (d )  still  remains  behind  in  the  uter- 
ine cavity  above  the  internal  os  (t). 
c.  Cavity  of  ovum;  o,  lower  pole  of 
ovum:  p,  placenta;  e,  external  os;  v,  va- 
ginal wall;  b,  blood-clots  in  the  cavity 
or  ovum. 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR. 


349 


toxemia;  while  in  others  the  fetus  will  suffer  only  from  the  prolonged  effect  of 
the  poison,  the  uterus  having  so  great  a  resistant  power  against  the  toxin.  In 
the  latter  condition  the  irritability  of  the  uterus  has  a  mechanical,  and  not  a  toxic 
origin.  The  non-elimination  of  carbonic  acid  gas,  in  diseases  of  the  heart,  lungs, 
and  liver;  or  violent  mental  shock  or  excitement,  may  interrupt  pregnancy;  but 
how  this  latter  acts  is  not  known.  Anemia,  tuberculosis,  infectious  diseases  with 
high  temperature,  especially  when  the  latter  is  suddenly  developed,  are  also  causes. 
The  local  causes  include  all  causes  of  acute  or  chronic  pelvic  congestion,  such  as 
malformations  and  malpositions  of  the  uterus,  especially  retro-displacements; 
metritis,  endometritis,  salpingitis,  tumors,  malignant  disease;  excesses  in  sexual 
intercourse  in  the  newly  married;  traumatisms,  as  a  blow  or  a  fall;  criminal  use  o 
instruments;  all  causes  of  obstructed  venous  return.  Perhaps  the  most  impor- 
tant is  previous  uterine  disease,  such  as  endometritis,  which  is  quite  common. 


Week. 

Month. 

Number  ok 
Casus. 

Percentage  of 
Interruption. 

4 

I. 

6 

i§ 

10  Not  Noted. 

8 

II. 

61 

9.61%    ) 

lO 

2i 

40 

6.29%    l 

232  Abortions. 

12 

III. 

131 

20.63%   ) 

14 

3^ 

21 

3-31%  \ 

i6 

IV. 

62 

9.76% 

i8 

4h 

9 

1.42%  f 

20 

V. 

35 

5-5 1  f« 

175  Miscarriages. 

22 

5* 

9 

1.42%  \ 

24 

VI. 

28 

4.42%  ) 

26 

6i 

1 1 

1-73%^ 

28 

VII. 

47 

7.40%  \ 

30 

7i 

14 

2.20%  1 

32 

VIII. 

8^ 

65 

10.26% 
2.37%  ( 

218  Premature  Labors. 

34 

15 

3^^ 

IX. 

50 

7.99%  \ 

3« 

9i 

27 

4.26%  / 
Total 

635  Interrupted  Pregnancies. 

2,  The  causes  in  the  ovum,  and  embryo  are  many  of  them  secondary  to  morbid 
conditions  in  the  mother,  but  at  the  same  time  are  direct  causes  of  interrupted 
pregnancy.  The  most  frequent  are  those  which  interfere  with  the  nutrition 
or  cause  the  death  of  the  embryo  or  fetus,  and  include  decidual  and  placental 
syphilis,  inflammations,  and  low  situations  of  the  placenta.  Less  frequent 
causes  are  other  diseases  and  anomalies  of  the  decidua,  chorion,  amnion,  liquor 
amnii,  placenta,  umbilical  cord,  and  the  fetus  itself,  which  produce  the  same 
result  (see  pages  191  to  243).  As  a  rule,  the  fetus  after  death  acts  like  a  foreign 
body  in  the  uterus,  although  now  and  then  it  is  retained  for  some  time,  but 
rarely  over  two  weeks. 

3.  Chief  among  the  paternal  causes  is  syphilis,  resulting  in  syphilitic  sper- 
matozoa, syphilitic  changes  in  the  placenta  and  fetus,  occurring  in  some  instances 
with  no  sign  of  the  disease  in  th'e  mother;  tuberculosis;  extreme  youth  or  old 
age;  great  constitutional  depression,  or  exhaustion  from  any  cause. 

Relative  Frequency. — The  principal  causes  in  the  order  of  their  frequency 
are  (i)  diseased  endometrium;  (2)  retro-displacements  of  the  uterus,  with 
or  without  adhesions;  (3)  syphilis;  (4)  kidney  insufficiency,  toxemia;  (5) 
criminal  interference;  (6)  low  insertion  of  the  placenta. 


350 


PATHOLOGICAL  PREGNANCY. 


Recurrent  Interruptions._ — The  most  frequent  causes  of  instances  of  repeated 
interruptions  in  the  same  individual  are  (i)  disease  of  the  endometrium;  (2) 
retro-displacements;  (3)  syphilis;  (4)  toxemia.  In  some  instances  the  cause 
is  so  pronounced  and  permanent,  especially  in  cases  Of  chronic  pelvic  inflam- 
mations, that  a  tendency  to  abort  at  the  same  period  in  successive  pregnancies 
exists,  thus  giving  rise  to  the  term  "the  abortion  habit."  Some  abortions 
occur  without  any  assignable  cause,  or  from  such  slight  cause  that  the  accident 
has  been  ascribed  to  an  "  irritable  uterus."  As  has  been  frequently  pointed  out 
by  different  observers  (Winckel),  a  striking  feature  in  the  study  of  the  etiology  is 
the  number  of  preceding  premature  interruptions  of  pregnancy. 

In  407  abortions  and  miscarriages  I  found  38  women,  or  9.1  per  cent., 
who  had  experienced  previous  abortions  or  miscarriages;  103,  or  24.7  per 
cent.,  who  had  experienced  previous  premature  spontaneous  labors;  and 
141,  or  34  per  cent.,  who  had  experienced  previous  interrupted  pregnan- 
cies. Among  218  spontaneous 
premature  labors,  there  were 
15  women,  or  6.9  per  cent., 
who  had  experienced  previous 
abortions  or  miscarriages;  44, 
or  20.2  per  cent.,  who  had  ex- 
perienced previous  premature 
labors;  and  59,  or  26  percent., 
who  had  experienced  previous 
interrupted  pregnancies.  The 
most  striking  fact  shown  in 
the  foregoing  figures  is  the 
large  number  of  previous  un- 
timely interruptions  of  preg- 
nancy; for,  as  the  figures 
prove,  among  407  women  who 
aborted  and  miscarried,  141, 
or  34  per  cent.,  suffered  from 
previous  premature  interrup- 
tions of  pregnancy;  and 
among  the  218  cases  of  pre- 
mature labor,  59,  or  26  per 
cent.,  had  experienced  pre- 
vious untimely  interruptions 
of  pregnancy. 
Symptoms. — The  symptoms  of  interrupted  pregnancy  vary  with  the  different 
months  of  gestation;  but  usually  premonitory  symptoms  of  pelvic  congestion 
occur,  and  the  characteristic  symptoms  follow — namely,  hemorrhage,  pain, 
dilatation  of  the  os,  descent  and  discharge  of  the  ovum,  embryo,  or  fetus. 
Great  variations  in  symptoms  occur  between  the  first  and  thirty-eighth  weeks 
of  gestation.  In  the  early  weeks  the  clinical  phenomena  often  resemble  merely 
an  exaggerated  menstrual  epoch,  while  at  the  eighth  month  all  the  phenomena 
of  labor  at  term  are  present.  A  marked  prodrome  of  spontaneous  abortion  and 
miscarriage  is  a  tendency  to  syncope,  and  it  should  be  remembered  that  abortions 
or  miscarriages  occurring  suddenly  are  rarely  accidental  or  spontaneous. 

Clinical  Phenomena. — i.  Abortion:  In  abortion — namely,  before  the  be- 
ginning of  the  fourth  month — ^the  clinical  picture  presented  by  the  emptying 
of  the  uterus  is  usually  altogether  different  from  that  of  an  interrupted  preg- 


FiG.  485. — Flesh  Mole. — {Atithor's  Case.) 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR. 


351 


nancy  occurring  subsequently.  During  the  first  three  months  the  ovum  is 
expelled  as  a  whole,  or  broken  up,  with  more  or  less  profuse  hemorrhage;  hence 
it  is  that  usually  but  a  single  stage  of  labor  can  be  recognized ;  while  after  the 
third  month  the  course  of  labor  corresponds  more  and  more  with  parturition 
at  term,  and  in  most  instances  three  stages  of  labor  can  be  distinctly  differen- 
tiated. In  the  first  six  weeks  we  most  frequently  have  "ovular  abortions," 
so  called  because  the  embryo  is  still  indistinguishable,  the  ovum  being  dis- 
charged intact  (see  Pathology)  and  unruptured,  with  marked  hemorrhage 
but  with  little  or  no  pain;  the  time  of  occurrence  is  apt  to  correspond  with 
the  menstrual  epoch,  and  the  little  pain  and  backache  present  are  attributed 
to  menstruation  and  to  the  discharge  of  clots  through  a  contracted  cervix,  the 
ovum  passing  away  unnoticed. 
From  the  sixth  to  the  twelfth  week, 
"embryonal  abortions"  are  more 
common,  so  called  because  the 
human  form  has  not  yet  been  fully 
assumed.  In  these  we  observe  pro- 
dromal symptoms  of  pelvic  conges- 
tion; the  pain  and  hemorrhage  are 
more  severe ;  there  is  first  an  escape 
of  the  embryo,  followed  after  a 
varying  period,  which  resembles 
somewhat  the  prolonged  third  stage 
at  term,  by  the  retained  decidua, 
chorion,  amnion,  and  rudimentary 
placenta.  The  occurrence  of  abor- 
tion at  this  time  is  often  preceded 
and  accompanied  by  active  symp- 
toms, such  as  syncope,  nausea, 
slight  rigors,  backache,  increased 
vaginal  secretion,  frequency  of 
micturition,  thirst,  pallor,  and,  in 
some  cases,  nervous  symptoms. 
Later  the  pain  in  the  back  in- 
creases, and  is  perhaps  attended 
with  a  feeling  of  intrapelvic  pres- 
sure; free  hemorrhage  occurs,  large 
clots  are  passed  from  time  to  time, 
and  finally  the  ovum  is  expelled 
intact  or  in  portions.  For  the 
symptoms  of  threatened,  inevit- 
able, complete,  incomplete,  neglected,  concealed,  missed,  and  criminal  abortions, 
see  Diagnosis. 

2.  Miscarriage  or  immature  labor:  As  gestation  advances  through  the  fourth, 
fifth,  sixth,  and  seventh  months,  we  find  the  clinical  phenomena  of  interruptions 
becoming  more  and  more  like  labor  at  term.  Three  stages  of  labor  can  now 
be  differentiated;  the  uterine  contractions  are  more  marked;  severe  voluntary 
bearing-down  efforts  appear;  there  is  less  and  less  hemorrhage  in  the  first 
stage,  and  more  at  the  end  of  the  second  and  during  the  third;  there  is  rupture 
of  the  membranes  and  a  gush  of  liquor  amnii;  occasionally  the  ovum  is  dis- 
charged intact  in  the  fourth,  fifth,  and  even  sixth  months — fetus,  liquor  amnii, 
membranes,  and  placenta  being  discharged  in  one  mass.     The  distinguishing 


Fig.  4S6. — Incomplete  Abortion.  Cervix 
Readily  Dilatable,  p,  Retained  placenta; 
b,  blood-clot;  s,  separated  vera;  d,  decidua 
vera;  h,  hemorrhagic  decidua  vera. 


352  PATHOLOGICAL  PREGNANCY. 

clinical  characteristics  of  interrupted  pregnancy,  at  this  period,  are  retention 
of  the  placenta,  which  is  completely  or  partially  adherent,  and  profuse  hemor- 
rhage in  the  third  stage. 

3.  Premature  labor:  In  comparing  the  course  of  the  process  in  immature  and 
premature  labors,  we  find  that,  clinically,  the  most  important  distinguishing 
feature  between  the  two  is  the  length  of  the  third  stage  of  labor.  After  the 
end  of  the  twenty-eighth  week  the  third  stage  of  labor  may  differ  in  no  way 
from  the  third  stage  at  full  term,  while  before  the  seventh  month  the  third 
stage  may  continue  days  and  weeks,  unless  its  course  is  artificially  terminated. 

Duration. — The  duration  of  interrupted  pregnancy  varies.  The  process 
may  be  quite  rapid,  or  days  or  weeks  may  elapse.  The  average  duration  of 
abortions  may  be  stated  as  between  twenty-four  and  thirty-six  hours.  Abortion 
may  be  instantaneous.  This  is  rare,  and  may  result  from  a  fall,  which  causes 
the  immediate  expulsion  of  the  ovum,  with  hemorrhage.  The  time  may 
equal  that  of  labor,  as  more  frequently  happens,  and  hemorrhage  and  uterine 
contractions  are  the  two  essential  features,  either  one  or  the  other  predomi- 
nating, or  both  being  of  about  equal  importance.  Slow  abortion  is  yet  more 
frequent  than  the  two  above  types.  The  causes  are  weak  uterine  contractions 
and  undue  resistance  of  the  cervix,  or  more  often  retention  of  the  placenta  with 
slow  detachment.  The  latter  feature  depends  on  the  extent  of  surface  oc- 
cupied by  the  chorionic  villi.  Placental  retention  occurs  about  fifteen  times 
in  a  hundred  cases.  Retarded  abortion  is  occasionally  caused  by  the  reten- 
tion of  the  ovum  in  the  cavity  of  the  cervix,  the  "  cervical  abortion"  of 
Schroeder  (Fig.  481). 

Diagnosis, — The  diagnosis  of  any  variety  of  interrupted  pregnancy,  abor- 
tion, miscarriage,  or  premature  labor  depends  upon  five  prominent  factors: 
namely,  (i)  the  diagnosis  of  pregnancy;  (2)  pain  (uterine  contractions);  (3) 
hemorrhage;  (4)  dilatation  of  the  cervix;  (5)  descent  of  the  ovum,  embryo, 
or  fetus  into  the  os. 

1.  Abortion. — The  same  difficulty  often  attends  the  diagnosis  of  an  abortion 
in  the  early  weeks,  as  the  positive  diagnosis  of  pregnancy  during  the  same 
time.  If  the  ovum  has  entered  the  internal  os  and  can  be  recognized  by  the 
examining  finger,  no  doubt  will  exist;, indeed,  in  most  cases  the  evidence  of 
profuse  hemorrhage  and  dilatation  of  the  cervix  will  be  sufficient.  The  ovum, 
if  intact,  can  be  distinguished  by  the  fact  that  it  becomes  tense  and  is  pressed 
downward  during  a  pain.  Clots  should  be  carefully  washed  in  water,  in 
order  that  portions  of  deciduae  or  fringe-like  chorionic  tissue  may  be  recog- 
nized. The  possible  existence  of  extrauterine  pregnancy  should  not  be  for- 
gotten, however,  for  in  this  condition  the  expulsion  of  decidua  may  occur. 
The  possibility  of  hemorrhage  from  cancer  of  the  cervix  or  other  morbid  con- 
ditions, already  described,  should  also  be  remembered.  The  physical  signs 
do  not  differ  materially  in  ovular  and  embryonic  abortions.  At  first,  on  vaginal 
and  bimanual  examination,  we  find  the  cervix  softer  than  would  be  expected; 
rather  profuse  hemorrhage  from  the  os;  the  body  of  the  uterus  either  hard 
from  tetanic  contraction  or  alternately  hard  and  soft.  Later,  after  several 
hours  perhaps,  dilatation  of  the  os  is  observed;  the  ovum  descends  and  may 
be  palpated  through  the  os  with  the  examining  finger,  and  perhaps  there  is 
effacement  of  the  angle  of  anteflexion  which  exists  early  in  pregnancy  between 
the  cervix  and  body  (Tamier's  sign).  This  sign  of  inevitable  abortion,  de- 
scribed by  Tamier,  is  by  no  means  constantly  present.  It  is  most  important, 
at  this  time,  to  be  able  to  distinguish  with  the  examining  finger  between  the 
ovum   and    a   blood-clot    situated    just  within   the    os.     In  threatened  abortion 


ABORTION,  IMMATURE  AND  PREMATURE   LABOR.  353 

the  clinical  picture  shows  a  hemorrhage  bright  in  color,  free  from  clots,  inter- 
mittent in  character,  fairly-  persistent,  and  moderate  in  amount;  there  is 
little  pain  or  none  at  all;  the  os  is  somewhat  dilated,  but  does  not  allow 
the  passage  of  the  finger;  the  uterus  is  soft,  anteflexed,  and  intermittent  con- 
tractions are  infrequent.  The  symptoms  may  subside,  or  persist  and  result 
in  a  complete  or  an  incomplete  abortion.  As  long  as  a  chance  of  the  subsidence 
of  the  symptoms  exists,  the  abortion  is  said  to  be  threatened.  In  inevitable 
abortion  the  hemorrhage  is  persistent,  increasing  in  amount,  and  contains  clots 
and  fragments  of  the  ovum  and  liquor  amnii;  pain  and  uterine  contractions 
are  present  and  increase  in  severity ;  the  os  is  dilated  and  admits  the  examining 
finger,  which  palpates  the  ovum  within  the  os;  the  uterus  is  alternately  soft 
and  hard,  or  is  tetanically  contracted.  The  ovum  perishes  and  is  expelled, 
or  occasionally  is  retained,  as  in  missed  abortion.  In  complete  abortion  there 
is  practically  no  hemorrhage;  pain  is  absent;  a  slight  discharge  resembling 
lochia  and  containing  small  shreds  of  decidua  is  present;  the  os  is  closed;  the 
uterus  is  hard  and  well  contracted,  and  involution  is  progressing  normally; 
there  is  a  rapid  subsidence  of  all  the  probable  signs  of  pregnancy.  The  exami- 
nation of  the  mass  that  has  been  expelled,  which  should  always  be  made,  will 
give  the  best  results  if  the  clots  and  blood  are  removed  by  washing  in  clean 
water.  In  the  case  of  complete  abortion  the  deciduae  will  be  seen  closely  em- 
bracing the  mass,  since  the  line  of  separation  is  in  the  spongy  part.  In  order 
to  detect  any  imperfection  in  the  membranes,  it  is  well  to  float  them  upon 
the  surface  of  the  water,  when  their  structure  will  be  clearly  seen.  In  incom- 
plete abortion  hemorrhage  is  persistent,  but  varies  in  amount;  it  is  at  first  bright 
in  color,  later  dark  brown,  thick,  and  offensive;  attacks  of  intermittent  uterine 
pain,  resembling  "after-pains,"  are  present;  the  lochia  may  contain  shreds 
of  decidua,  amnion,  or  rudimentary  placenta;  the  os  readily  admits  the  finger, 
and  decidua,  membrane,  pieces  of  placenta,  and  blood-clots  are  found  in  the 
uterine  cavity;  the  uterus  remains  persistently  large  and  soft;  involution  is 
absent,  and,  with  the  exception  of  the  enlargement  of  the  uterus,  the  probable 
signs  of  pregnancy  disappear.  To  sum  up :  if  the  pain  and  discharge  continue 
from  time  to  time,  if  the  uterus  is  soft  and  boggy,  if  the  os  remains  patulous, 
and  if  the  examining  finger  detects  retained  portions  of  the  ovum,  the  abortion 
is  incomplete.  In  neglected  abortion  the  clinical  picture  is  the  same  as  in  incom- 
plete abortion,  with  the  addition  of  the  symptoms  of  local  and  general  septic 
processes  (see  Fever).  In  concealed  abortion — namely,  in  cases  in  which  the 
embryo  perishes  but  is  not  expelled — the  clinical  phenomena  are  absence 
of  hemorrhage  and  of  pain;  no  discharge;  the  cervix  is  soft;  the  os  is  closed, 
but  may  admit  the  finger  with  firm  pressure;  the  uterus,  soft,  flabby,  has  lost 
the  usual  resiliency  of  pregnancy,  and  fails  to  increase  in  size,  rather  diminishing; 
the  signs  of  pregnancy,  aside  from  the  enlarged  uterus,  subside.  In  missed 
abortion  there  are  all  the  clinical  signs  of  threatened  abortion,  with  a  subsidence 
of  the  same,  followed  by  those  of  either  concealed  or  neglected  abortion.  In 
induced  or  criminal  abortions  the  clinical  phenomena  may  not  differ  from  those 
of  spontaneous,  complete,  or  incomplete  abortions. 

2.  Miscarriage. — In  the  second  third  of  gestation  the  diagnosis  of  either 
pregnancy  or  a  threatened  interruption  becomes  much  easier,  because  the 
signs  of  pregnancy  are  all  more  marked,  the  symptoms  of  miscarriage  are  of 
greater  severity  than  those  of  abortion,  fetal  parts  and  uterine  contractions 
are  readily  recognized,  and  there  are  the  formation  of  a  bag  of  membranes  and 
the  escape  of  liquor  amnii. 


354  PATHOLOGICAL  PREGNANCY. 

3.  Premature  Labor. — The  diagnosis  of  premature  labor  becomes  practi- 
cally the  diagnosis  of  labor  at  term.     (See  Part  IV.) 

Differential  Diagnosis. — Abortion  and  miscarriage  are  to  be  differentiated 
from  menorrhagia,  metrorrhagia,  dysmenorrhea,  and  ectopic  gestation.  Differ- 
entiation is  also  called  for  between  threatened  and  inevitable,  complete  and 
incomplete  abortion,  and  between  an  ovum  and  a  blood-clot.  It  is  a  matter 
of  importance  to  distinguish  between  threatened  and  inevitable  abortion,  since 
the  treatment  of  the  latter  condition  is  radically  different  from  that  of  the 
former.  In  threatened  abortion  the  discharge  is  usually  of  a  bright  red  color 
and  free  from  clots,  whereas  in  inevitable  abortion  large  clots  and  perhaps  por- 
tions of  ovum  may  be  present.  In  threatened  abortion  there  is  little  or  no  pain, 
while  in  inevitable  abortion,  especially  after  the  first  month,  the  pain  may  be  con- 
siderable. Instances  have  been  recorded  in  which  the  os  has  admitted  two  fin- 
gers, but  has  subsequently  closed  and  the  symptoms  have  disappeared ;  in  which 
fragments  of  decidua  have  been  expelled  from  the  uterus  and  yet  the  case  has 
gone  on  to  term;  but  in  general  it  may  be  said  that  if  there  are  much  pain  and 
profuse  hemorrhage,  if  the  cervix  admits  the  finger,  and  if  the  ovum  can  be  felt, 
there  is  little  doubt  as  to  the  result.  Tamier's  sign  has  already  been  mentioned 
(page  352).  To  distinguish  between  a  complete  and  an  incomplete  abortion  is  also 
important,  with  reference  to  treatment,  in  order  to  determine  whether  the  uterine 
contents  have  been  wholly  or  only  partly  expelled.  The  discharge  of  an  intact 
ovum  will,  of  course,  settle  the  question.  If  the  hemorrhage  and  pain  cease,  if 
the  OS  is  closed,  and  if  the  uterus,  although  still  large,  is  firmly  contracted,  and 
there  is  a  disappearance  of  the  signs  of  pregnancy,  especially  the  milk  secretion, 
the  abortion  is  probably  complete.  In  order  to  differentiate  an  ovum  from  a 
blood-clot  by  the  palpating  finger,  Holl's  sign  may  be  of  service,  (a)  During 
a  pain,  caused  by  uterine  contraction,  the  ovum,  increased  in  size,  smooth 
and  tense,  advances,  while  a  blood-clot  does  not  become  tense,  nor  does  it 
advance.  (6)  The  ovum  presents  a  tense,  resilient,  and  convex  surface,  while 
the  blood-clot  is  cone-shaped,  apex  downward,  and  non-elastic,  (c)  If  pressure 
is  exerted  on  the  fundus,  in  case  the  mass  is  an  ovum,  motion  is  not  transmitted 
to  it  as  a  whole,  on  account  of  its  resiliency,  while  the  blood-clot  would  be 
moved  en  masse,  on  account  of  its  solidity. 

Prognosis. — Mortality:  Among  the  242  cases  of  abortion  studied  there  were 
no  deaths  from  any  cause;  among  the  175  cases  of  miscarriage,  one  death  from 
placenta  prsevia  and  ruptured  uterus  occurred;  and  in  175  spontaneous  pre- 
mature labors  there  were  four  deaths, — one  from  placenta  prasvia  and  hemor- 
rhage, one  from  sepsis  and  bronchopneumonia,  two  from  nephritis  and  eclamp- 
sia. These  cases  were  all  cared  for  in  their  own  homes.  The  prognosis  of 
spontaneous  interruptions  is  good,  under  intelligent  treatment,  and  when  the 
cause  of  the  interruption  is  not  in  itself  a  menace  to  life;  such  as  high  tempera- 
ture from  an  acute  general  disease,  placenta  praevia,  nephritis,  or  eclampsia.  In 
criminal  interruptions,  on  the  other  hand,  the  prognosis  is  bad,  by  reason  of 
the  unskilfulness  of  the  procedure  admitting  air  and  septic  matter  into  the 
uterus,  the  secrecy  surrounding  the  affair,  and  the  accompanying  moral  shock. 
In  neglected  or  improperly  treated  cases  the  mother  is  exposed  to  the  dangers 
of  immediate  and  late  septic  infection,  of  hemorrhage,  of  endometritis,  and 
to  a  long  train  of  remote  evils,  including  the  liability  to  subsequent  abortions. 

The  irnmediate  dangers  of  interrupted  pregnancy  are:  (i)  hemorrhage;  (2) 
retention  of  an  adherent  placenta;  (3)  sepsis;  (4)  tetanus;  (5)  perforation  of 
the  uterus  with  a  curette. 

I.  Hemorrhage.     This  complication  causes  alarm  only  when  it  is  present 


ABORTION,   IMMATURE  AND   PREMATURE   LABOR. 


355 


in  an  extreme  degree.  It  is  the  general  symptoms  resulting  which  are  especially 
to  be  feared;  namely,  the  tendency  to  syncope,  disturbances  of  the  special 
senses,  etc.  Hemorrhage  predisposes  to  septicemia,  but  in  itself  is  not  often 
fatal.  Persistent  hemorrhage,  though  slight,  induces  a  condition  of  weakness, 
strongly  predisposing  to  infection  later.  Hemorrhage  in  abortion,  as  a  promi- 
nent symptom  in  the  early  stages  of  the  242  cases  studied,  occurred  in  85.57 
per  cent.,  thus  agreeing  with  what  has  already  been  stated  regarding  the  fre- 
quency of  hemorrhage  at  the  outset  of  abortion  cases  proper.  Of  these  242 
cases,  214  were  subjected  to  curettage,  shortly  after  being  seen,  and  in  only 
one  case  was  there  subsequent  hemorrhage.  In  the  175  miscarriage  cases, 
hemorrhage  as  a  prominent  symptom  before  or  during  labor  occurred  in  66.29 
per  cent,  of  cases;  iii  of  these  175  cases  were  subjected  to  curettage  shortly 
after  being  seen,  and  subsequent  hemorrhage  took  place  in  five  cases.  In 
the  218  cases  of  spontaneous  premature  labor,  hemorrhage  before  or  during 
labor  occurred  in  6.42  per  cent.,  and  after  delivery  in  four  cases.  Eight  of 
these  hemorrhage  cases  were  the 
subject  of  placenta  praevia. 

2.  Retention  of  adherent  placen- 
ta, which  demands  an  expression, 
a  digital  or  manual  removal,  or  a 
curettage  after  removal,  is  com- 
mon in  the  fourth  and  fifth  months, 
and  becomes  less  so  as  full  term  is 
approached  (Fig.  486). 

2,.  Septic  infection.  This  may  be 
due  to  decomposition  of  retained 
placenta,  or  to  faulty  asepsis  and 
antisepsis  in  the  technique  of  the 
treatment .  The  pulse  usually  gives 
the  first  signal,  which  is  followed  by 
fever,  rigors,  suppression  or  putrid- 
ity of  the  lochia,  etc.  Death  may 
come  quickly  or  slowly,  or  by  care 
it  may  be  warded  off,  though  there 
may  be  left  behind  lesions  of  the 
uterus  and  its  adnexa.  I  found 
that  fever  as  a  complication  occur- 
red, among  242  abortions,  in  11.57 

per  cent.,  two-thirds  of  this  only  being  due  to  sepsis;  in  1 75  miscarriages  fever  as 
a  complication  took  place  in  21.71  per  cent.,  three-fourths  of  this  being  caused 
by  septic  infection;  and  in  218  spontaneous  premature  labors  fever  occurred  in 
19.27  per  cent.,  one-half  only  of  this  amount  being  due  to  uterine  sepsis.  Pyemia 
is  especially  common  after  abortion,  infection  taking  place  usually  at  the 
placental  site. 

4.  Tetanus.  This  is  frequently  reported  as  a  sequel  to  abortion  and  mis- 
carriage, but  is  most  often  an  accident  in  the  course  of  a  general  septicemia. 
In  the  242  abortions,  175  miscarriages,  and  218  spontaneous  premature  labors 
already  referred  to,  no  case  of  tetanus  occurred.  Although  a  rare  condition,  it 
was  observed  twenty-one  times  by  Bennington,  who  collected  41  cases  of  puer- 
peral tetanus. 

5 .  Perforation  of  the  uterine  wall.  Numerous  cases  of  perforation  of  the  uter- 
ine wall,  during  curettage  after  abortions  and  miscarriages,  have  occurred.     The 


Fig.  487. — ^Placental  Polyp  in  Situ.  Drawn 
from  a  specimen,  u,  Utero-placental  arter- 
ies; i,  internal  os;  /,  lower  portion  of  polyp 
hanging  in  vagina;  h,  blood-injected  placen- 
tal remnants;  e,  external. os. — (Bumm.) 


356  PATHOLOGICAL   PREGNANCY. 

danger  of  perforation  is  reduced  to  a  minimum  if  the  curette,  when  introduced 
into  the  uterus,  is  passed  cautiously  to  the  fundus,  and  then,  with  a  firm  down- 
ward stroke,  is  used  to  clear  the  uterine  walls,  especially  at  the  horns. 

The  remote  dangers  of  interrupted  pregnancy  are:  (i)  subinvolution  and  dis- 
placements; (2)  septic  sequelae ;  (3)  endometritis;  (4)  polypi;  malignant  disease; 
(5)   sterility;  (6)  anemia;  (7)   recurrence;   (8)  neuroses. 

1.  Subinvolution  and  displacements.  Involution  takes  place  more  quickly 
than  after  labor  at  term,  unless  the  abortion  is  incomplete;  its  progress  being 
delayed  by  septicemia  and  retention  of  the  membranes.  Subinvolution  is 
not  uncommon  after  interrupted  pregnancy;  and  often  causes  displacements. 
Subinvolution  is  at  times  accompanied  by  a  tendency  to  metrorrhagia,  which 
leads  to  anemia  and  debility. 

2.  Septic  sequelcB.  Local  or  general  sepsis,  which  sometimes  follows  abortion, 
may  each  induce  a  train  of  serious  sequelae.  The  former  is  responsible  for 
endometritis,  metritis,  perimetritis,  parametritis  and  pelvic  abscess,  salpingitis, 
oophoritis,  and  sterility.  Remote  infections  may  develop  as  sequelae,  as  shown 
in  the  occasional  supervention  of  suppurative  arthritis  and  other  pyaemic 
processes  at  a  distance  from  the  pelvis. 

3.  Endometritis.  As  regards  endometritis,  diametrically  opposite  opinions 
are  maintained.  Stumpf,  Winter,  and  Puppe  say  that  it  is  not  the  result 
of  abortion  and  retention  of  membranes,  and  point  to  Veit's  curetted  cases, 
in  which  the  endometritis  had  to  be  treated  after  the  puerperium  was  ended. 
They  neglect  to  suggest  the  possibility  of  a  prior  abortion,  expectantly  treated, 
being  at  the  bottom  of  the  trouble.  Reference  to  the  figures  given  below  shows 
a  15.3  greater  percentage  of  subsequent  pregnancies  when  the  secun dines 
were  instrumentally  removed,  which  is  tolerably  fair  evidence  that  these 
cases  were  free  from  endometritis. 

4.  Polypi;  Malignant  disease.  The  non-septic  residue  of  the  embryo, 
persisting  within  the  uterus,  may  become  nourished  and  develop  into  decidual 
and  placental  polypi,  and  even  into  that  rare  and  peculiar  formation  known 
as  deciduoma  malignum,  although  this  is  seen  more  commonly  after  molar 
pregnancy  (Fig.  487)- 

5.  Sterility.  Many  authorities  hold  to  the  opinion  that  a  uterine  mucous 
membrane,  completely  renewed  after  an  abortion,  by  reason  of  a  curettage, 
is  less  capable  of  playing  the  part  of  a  decidua  of  pregnancy  than  one  that 
has  done  so  before  in  whole  or  in  part.* 

Certainly,  my  figures  lead  one  to  a  far  different  conclusion  from  Puppe 's. 
Of  119  cases  treated  by  instrumental  curettage,  38,  or  31.9  per  cent.,  had  expe- 
rienced one  or  more  previous  interrupted  pregnancies;  5,  or  4.2  per  cent., 
suffered  subsequently  in  the  same  way;  48,  or  40.3  percent.,  gave  birth  to 
living  children  at  term;  and  21,  or  17.6  per  cent.,  were  found  to  be  pregnant 
from  the  fourth  to  the  eighth  month  when  visited.  These  observations  were 
made  at  the  patients'  homes  and  the  children  were  seen.  Of  28  cases  of  abortion 
expectantly  treated,  10,  or  35.7  per  cent.,  had  had  similar  previous  experiences. 
None  suffered  from  subsequent  interrupted  pregnancies;  7  gave  birth  to  living 
children  at  term  afterward  (25  per  cent.);  5,  or  17.8  per  cent.,  were  found 
to  be  pregnant  from  the  fourth  to  the  eighth  month  when  visited. 

6.  Anemia.  The  hemorrhage  which  accompanies  the  act  of  abortion  may 
be  so  profuse,  especially  if  the  pregnancy  is  well  advanced,  that  a  condition 

*  Puppe:  "  Untersuchungen  iiber  die   Folgezustande  nach  Abortus."  Inaug.  Dissert., 
Berlin,  1890. 


ABORTION,  IMMATURE  AND  PREMATURE  LABOR.  357 

of  acute  anemia,  with  all  its  sequelas,  may  be  established.     Hemorrhage  due 
to  subinvolution  has  been  mentioned  (page  354). 

7.  Recurrence.  The  tendency  to  a  recurrence  of  abortion,  and  to  the  estab- 
lishment of  habitual  abortion,  may  be  set  down,  with  justice,  as  a  sequela  of 
interrupted  pregnancy,  which  is  highly  important  by  reason  of  its  frequency. 

8.  Netiroses.  Finally,  American  authorities  enumerate  a  tendency  to 
functional  neuroses,  and  even  to  psychoses,  as  one  of  the  sequelae  of  the  inter- 
ruption of  gestation.     The  pathogeny  of  these  affections  is  obscure. 

Treatment. — i.  Prophylaxis:  In  habitual  premature  interruption  the  cause 
or  causes  should  first  be  sought.  The  various  conditions  which  are  known 
to  favor  miscarriage  should  be  considered,  one  after  the  other;  the  uterus 
itself  should  first  be  examined;  if  conception  has  not  taken  place,  any  anomaly 
which  is  apparent,  such  as  malposition,  endometritis,  laceration  of  the  cervix, 
etc.,  should  receive  suitable  treatment.  If  syphilis  exists  in  either  parent, 
a  thorough  course  of  antisyphilitic  treatment  for  several  months  should  be  in- 
sisted upon,  irrespective  of  previous  medication;  uterine  displacements  should 
be  corrected,  and  the  uterus  may,  if  necessary,  be  kept  in  position  by  a  suitable 
pessary  for  the  first  three  months,  care  being  taken,  however,  that  the  pessary 
causes  no  irritation ;  endometritis  or  other  intrapelvic  disease  should  be  suitably 
treated.  For  the  various  morbid  conditions  causing  sterility,  and  their  appro- 
priate treatment,  the  student  is  referred  to  works  on  gynecology.  If  the  woman 
is  already  pregnant,  the  uterus  is  beyond  the  reach  of  treatment,  save  that  a 
pessary  may  be  worn  for  retroversion,  during  the  first  three  or  four  months. 
Coitus  should  be  forbidden  during  pregnancy,  and  rest  in  bed  for  a  few  days 
before  and  after  the  dates  corresponding  to  the  usual  menstrual  epochs  is 
advisable;  the  use  at  this  time  of  the  fluid  extract  of  viburnum  prunifolium, 
and  the  uterine  sedatives — hydrastis  canadensis,  Jamaica  dogwood,  and  Pul- 
satilla— is  also  advised.  Everything  that  causes  mental  or  physical  shock  or 
fatigue — excitement  or  worry ;  exercises,  walking,  standing,  prolonged  physical 
exertion ;  improper  diet ;  the  use  of  violent  purgatives ;  railway  journeys  or  auto- 
mobile riding  over  rough  roads — must  be  avoided.  Conditions  which  predispose 
to  abortion,  such  as  severe  coughing,  vomiting,  and  intercurrent  diseases  of 
pregnancy,  should  receive  prompt  attention.  Another  method  of  dealing  with 
habitual  abortion  is  to  forbid  pregnancy  until  a  given  interval  has  elapsed. 
This  is  probably  the  best  means  for  meeting  the  indication,  for  the  tendency 
to  abortion  is  not  inborn  but  acquired,  and  physiological  rest  will  enable  the 
uterus  to  outlive  this  faulty  condition. 

2.  Threatened  interruption:  Abortion  becomes  inevitable  when  the  ovum 
is  dead;  this  condition,  however,  in  the  early  months  can  only  be  inferred. 
The  criteria  upon  which  to  base  an  assumption  of  this  event  are  two:  the 
amount  of  hemorrhage,  which  when  extensive  argues  for  the  existence  of  a 
corresponding  degree  of  separation  of  the  ovum,  and  the  degree  of  dilatation  of 
the  OS.  We  should  not  act  upon  the  supposition  that  death  of  the  ovum  has 
occurred,  for  the  patient  should  be  given  the  benefit  of  the  doubt,  but  wait 
until  a  certain  period  has  expired,  during  which  the  hemorrhage  may  subside 
and  the  os  close.  After  the  sixth  month  we  can  tell  whether  the  fetus  is  dead, 
and  in  every  case  an  attempt  should  be  made  to  save  the  life  of  the  child.  The 
patient  should  be  kept  in  bed  in  a  quiet,  darkened  room;  the  rectum  and  bladder 
attended  to;  simple  liquid  diet  used,  and  physical  and  mental  rest  secured 
by  sedatives.  If  marked  symptoms  are  present,  i  of  a  grain  (0.016  gm.)  of 
morphin  may  be  given  subcutaneously,  and  the  bromides,  with  viburnum 
prunifolium  and  hyoscyamus,  administered  by  mouth;  the  patient  remaining 


358  PATHOLOGICAL  PREGNANCY. 

in  bed  for  several  days  after  all  symptoms  have  disappeared.  A  useful  pre- 
scription in  these  cases  is:  Sodium  bromide,  half  an  ounce  (i6  gm.);  simple 
eUxir,  three  ounces  (96  gm.);  tincture  of  hyoscyamus  and  extract  of  viburnum 
prunifolium,  of  each  half  an  ounce  (16  gm.).  Take  two  teaspoonfuls,  in  a 
sherry  glass  of  water,  every  three  hours.  It  may  be  necessary  to  continue  this 
line  of  treatment  several  weeks,  and  it  is  justifiable  when  we  observe  an 
increase  in  the  size  of  the  uterus  and  other  signs  that  the  fetus  is  alive.  The 
management  should  be  the  same,  whether  the  chances  are  in  favor  of  or  against 
saving  the  ovum,  and  the  general  principles  of  treatment  are  the  same  as  in 
the  prophylaxis  of  abortion.  The  best  sedative  is  opium,  which  may  also  be 
required  as  an  anodyne  if  pain  is  present.  If  the  loss  of  blood  is  excessive,  some 
hemostasis  must  be  effected,  but  ice-bags  and  tampons  are  alike  contraindicated,. 
since  either  might  have  an  oxytocic  action.  Our  only  resources  are  postural, 
viz.,  elevation  of  the  pelvis  and,  possibly,  cold  compresses  to  the  vulva.  If, 
after  several  hours,  it  becomes  evident,  from  the  extent  of  hemorrhage,  uterine 
contraction,  and  dilatation  of  the  os,  that  abortion  is  inevitable,  the  treatment 
for  that  condition  should  be  instituted.  If,  on  the  other  hand,  the  symptoms 
improve,  the  treatment  should  be  continued  until  hemorrhage  and  pain  have 
subsided,  and  in  any  case  for  at  least  forty-eight  hours.  After  this,  the  patient 
should  be  regarded  as  on  probation  for  a  week  longer,  if  there  is  any  recurrence 
of  pain  or  metrorrhagia. 

3.  Inevitable  interruptions;  early  abortions:  Authorities  are  at  variance  as 
to  the  indications.  Shall  the  emptying  of  the  uterus  be  left  to  nature,  or  is 
it  the  physician's  duty  to  evacuate  this  organ  at  once?  Is  it  possible  that  each 
of  these  plans  has  its  legitimate  field?  Or,  is  it  possible  to  combine  the  two 
plans,  by  a  compromise,  without  treatment?  All  methods. for  the  management 
of  inevitable  abortion  may  be  systematically  classified  as  follows:  (i)  Purely 
conservative  or  expectant  treatment.  Interference  is  altogether  interdicted,, 
and  sole  reliance  placed  upon  the  tampon,  vaginal  irrigation,  and  ergot.  (2)- 
Early  artificial  removal  of  the  decidua  or  placenta,  active  treatment  so  called, 
in  which  curettage  is  the  routine  plan.  (3)  An  intermediate  or  eclectic  method, 
in  which  intervention  is  resorted  to  only  in  order  to  control  hemorrhage  or 
sepsis.  The  indications  for  treatment,  in  all  cases  of  inevitable  abortion,  are 
the  same:  namely,  first,  to  control  the  hemorrhage;  and,  second,  to  secure 
complete  evacuation  of  the  uterine  contents.  Both  are  best  fulfilled  by  instru- 
mental curettage  of  the  uterus,  and  as  a  temporary  measure,  to  control  hemor- 
rhage while  preparations  for  curettage  are  in  progress,  the  vaginal  tampon 
is  most  valuable.  The  latest  observations  tend  to  show  that  in  abortions, 
contrary  to  the  generally  received  opinion,  the  separation  of  the  decidua  vera 
from  the  uterine  wall  takes  place  from  above  downward,  ai:id  that  consequently 
the  complete  removal  of  the  decidua  by  the  finger  seldom,  if  ever,  takes  place. 
Moreover,  the  removal  of  small  fragments  of  decidua  is  easily  accomplished 
by  the  curette,  while  it  is  difficult,  if  not  impossible,  by  the  finger.  Other 
advantages  of  the  curette  are  that  less  dilatation  of  the  cervix  is  necessary, 
the  operation  is  less  painful,  and  anesthesia  is  not  always  required.  I  advise, 
in  all  cases  of  inevitable  abortion  and  in  those  in  which  the  accident  has  already 
occurred  (incomplete),  that  the  patient  be  plainly  told  that  a  curettage  is 
necessary,  leaving  entirely  out  of  consideration  the  amount  of  hemorrhage 
as  an  indication  for  interference ;  and  if,  upon  explaining  the  danger  of  retained 
secundines  to  her,  consent  for  curettage  cannot  be  secured,  then  only  should 
the  first  method  of  purely  conservative  or  expectant  treatment  be  followed — 
namely,  relying  upon  the  vaginal  tampon,  irrigation,  and  ergot.     The  patient's 


ABORTION,   IMMATURE  AND   PREMATURE   LABOR. 


359 


consent  having  been  obtained,  curettage  is  performed  in  as  short  a  time  as 
possible.  The  vaginal  tampon  is  useful  in  all  cases  in  which  hemorrhage  is 
severe  and  the  curettage  cannot  immediately  be  performed;  it  effectually 
controls  hemorrhage,  aids  in  the  separation  of  the  decidua,  and  in  the  dilatation 
of  the  OS.  (For  curettage,  instrumental  and  digital,  and  vaginal  tamponade, 
see  Operations,  Part  X.) 

I   advocate   the    active    treatment   of    abortion,    inevitable    or   incomplete, 
by  reason  of  the  analyses  of  the  records  of  many  hundreds  of  cases,  treated 


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Fig.  48S. — Miscarriage  at  Five  and  a  Half 
Months;  Manual  Extraction  of  the  Pla- 
centa; Septic  Intoxication;  Curettage  on 
the  Fourth  Day. 


Fig.  489. — Incomplete  Early 
Abortion.  Septic  Intoxica- 
tion; Curettage 


by  various  methods,  and  especially  from  an  exhaustive  study  of  the  pathology, 
bacteriology,  duration,  complications,  sequelae,  and  treatment  of  242  cases; 
166  of  which  were  treated  by  instrumental  curettage;  45  by  combined  instru- 
mental and  digital  curettage;  3  by  digital  curettage  only,  and  28  by  a  purely 
expectant  treatment.  Contrasting  the  expectant  and  active  plans  of  treatment 
of  abortion,  I  believe  the  latter  is  less  dangerous  than  the  abortion  and  its 
sequelae  in  cases  of  retention,  and  curettage  makes  sure  that  everything  is 
removed;  involution  and  time  are  necessarv  for  convalescence  after  abortion; 


360  PATHOLOGICAL  PREGNANCY. 

the  one  is  hastened,  the  other  cut  short,  after  curetting;  this  is,  of  course,  a 
boon  to  the  working  classes;  the  expectant  plan  requires  two  weeks  for  itself 
alone;  after  instrumentation  the  patient  may  leave  her  bed  on  the  fifth  day; 
pain  and  physical  discomfort,  as  well  as  mental  perturbation,  are  less  than 
in  the  expectant  method;  moreover,  a  large  proportion  of  so-called  complete 
abortion  cases  are  followed  by  hemorrhages,  subinvolution,  acute  and  chronic 
sepsis;  hemorrhage  is  always  greater  with  expectant  treatment;  not  more 
than  half  an  ounce  is  lost  by  instrumentation,  before  the  fourth  month.  In 
the  first  two  months  and  a  half,  emptying  of  the  uterus  can  be  accomplished 
with  curettage  alone,  the  canal  admitting  the  finger  with  difficulty  and  pain 
if  anesthesia  is  not  used.  Uterine  atony  is  controlled  by  irrigation  and  uterine 
tamponade  with  gauze;  ergot  is  rarely  called  for,  the  placental  forceps  only 
occasionally.  If  curettage  for  any  reason  cannot  be  accomplished  at  once, 
the  vagina  may  be  tamponed  with  sterile  gauze  until  the  operation  can 
be  carried  out.  This  course  may  also  be  pursued  when  curettage  is  refused, 
and  the  gauze  packing  may  be  left  in  for  twenty-four  hours.  Again,  if  the 
accoucheur  is  a  beginner,  who  dreads  assuming  the  responsibility  of  forced 
dilatation  and  curettage,  he  is  justified  in  adopting  the  conservative  plan, 
and  in  temporizing  with  a  gauze  pack  until  dilatation  occurs.  Inevitable 
abortion  may  terminate,  in  a  small  number  of  cases,  in  expulsion  of  the  ovum 
almost  entire  in  which  case  it  is  arrested  in  the  cervical  canal.  Under  these 
circumstances  curettage  may  not  be  necessary,  as  hemorrhage  may  cease  after 
simple  extraction  with  the  finger  or  forceps.  In  case  the  ovum  is  too  large 
to  pass  through  the  os,  the  latter  may  be  dilated. 

Late  abortions.  In  the  management  of  late  abortions  the  treatment  which 
has  been  advised  for  early  abortions  is  preferable  during  the  early  portion 
of  the  second  third  of  gestation;  since  clinically  we  are  unable  to  draw  the 
line  so  sharply  between  early  and  late  abortion  as  some  authorities  would 
have  us  do.  With  the  advance  of  pregnancy  the  treatment  should  become 
less  and  less  aggressive,  until  it  gradually  merges  into  that  of  premature  labor 
and  labor  at  term.  The  real  criterion  of  late  abortions  is  the  marked  pro- 
longation of  the  third  stage  of  labor,  which  is  due  to  the  facts  that  placental 
development  has  occurred,  and  that  the  placenta  is  frequently  adherent  to 
the  uterus.  In  the  removal  of  an  adherent  placenta  the  manual  method,  as 
stated,  is  usually  preferable,  while  for  the  removal  of  the  decidua  the  curette 
is  to  be  preferred.  It  is  best  not  to  use  the  curette  to  remove  the  placenta 
after  the  twelfth  week.  It  is  not  consistent  or  safe  to  do  so,  and  as  a  greater 
number  of  abortions  occur  at  the  third  month,  the  method  of  treatment  must 
be  a  combined  one.  The  separation  of  the  placenta  is  readily  accomplished 
by  digital  curettage;  the  curette  remioves  the  decidua  vera.  Bimanual  com- 
pression of  the  fundus  uteri  by  tv/o  fingers  internally  and  the  other  hand  exter- 
nally upon  the  abdomen,  as  a  method  of  placental  expression,  is  quite  painful, 
frequently  ineffectual,  and  is  not  to  be  recommended. 

4.  Incomplete  and  septic  abortions:  If  the  fetus  has  been  expelled  from  the 
uterus,  the  membranes  and  placenta  remaining  behind,  the  indication  is  to 
curette  at  once,  even  if  forcible  dilatation  is  required.  In  suspected  and  estab- 
lished sepsis  the  greatest  care  must  be  used  in  all  examinations  and  operative 
procedures  not  to  open  up  new  areas  for  infection.  Sepsis  may  not  be  recog- 
nized as  such,  but  we  may  assume  that  it  is  present  if  a  high  pulse  exists,  with 
or  without  fever.  In  this  class  of  cases,  as  in  infection  after  labor  at  term,  I 
use  the  gentlest  means  to  clear  the  uterus  of  retained  material.  Usually  the 
finger  and  irrigation  are  sufficient.     In   exceptional  cases  I  still   resort  to  the 


ECTOPIC  GESTATION.  361 

dull  curette  where  the  size  of  the  uterine  cavity  or  the  nature  of  the  retained 
matter  do  not  allow  of  the  efficient  use  of  digital  curettage.  The  uterus  is  then 
irrigated  with  several  quarts  of  a  saline  or  antiseptic  solution,  and  further  intra- 
uterine treatment  is  contraindicated,  with  the  possible  exception  of  an  occasional 
irrigation,  most  carefully  administered.  The  remaining  treatment  of  septic 
abortion  does  not  differ  from  that  of  puerperal  sepsis  in  general. 

Premature  labor.  This  is  the  same  as  the  management  of  labor  at  full  term. 
(See  page  463-) 

After-treatment. — The  after-treatment  of  abortions,  miscarriages,  and  pre- 
mature labors  should  approach  as  nearly  as  possible  to  that  of  the  puerperium 
at  term.  (See  Part  VI.)  Unfortunately,  after  early  interruptions  of  pregnancies 
patients  insist  upon  making  light  of  the  condition,  leave  the  recumbent  position 
too  early,  and  generally  abandon  treatment  so  essential  for  the  attaining  of  proper 
involution.  Involution  is  relatively  slower  after  abortions  and  miscarriages  than 
during  the  normal  puerperium;  hence  the  dangers  of  subinvolution,  uterine  dis- 
placements, and  pelvic  inflammations  should  always  be  explained  to  the  patient, 
and  the  importance  of  the  same  attention  to  the  condition  as  after  labor  at  term. 
The  combined  and  persistent  use  of  ergot  and  strychnin  I  have  found  of  the 
greatest  value  in  hastening  involution  and  in  preserving  the  tone  of  the  uterine 
ligaments.  I  use  one  or  two  grains  (0.06  to  o.i  2  gm.)  of  ergotin,  and  one-thirtieth 
(0.002)  of  a  grain  of  the  sulphate  of  strychnin,  three  times  a  day,  in  capsules 
or  tablets.  As  lactation  is  absent,  this  function  does  not  constitute  an  objection 
to  the  use  of  these  drugs.  Vaginal  and  uterine  irrigation  is  unnecessary,  except 
after  incomplete  or  neglected  abortion,  or  miscarriage  with  symptoms  of  uterine 
sepsis.  Late  in  the  puerperium  very  hot  vaginal  irrigations  are  of  benefit  in 
assisting  involution.  Ergot  and  its  derivatives  must  not  be  given  until  the 
uterus  is  free  from  the  products  of  conception.  It  is  just  as  necessary  for  a 
physician  to  know  how  to  treat  abortion  as  it  is  to  treat  normal  labor,  and  the 
matter  should  receive  adequate  attention  in  the  schools. 


XX.  ECTOPIC  GESTATION. 

Definition. — Ectopic  gestation  or  extrauterine  pregnancy  consists  in  the 
development  of  the  fertilized  ovum  outside  of  the  uterine  cavity. 

Varieties;  Site. — Despite  the  occasional  alleged  development  of  the  ovum  in 
some  one  of  a  variety  of  atypical  localizations — ovary  (Fig.  490),  angle  of  uterus 
(Fig.  491),  abdominal  cavity,  etc. — the  vast  majority  of  cases  occur  within  some 
portion  of  the  Fallopian  tube ;  usually  toward  the  ovary  (Fig.  493).  This  variety 
is  known  as  the  ampullar.  Development  of  the  ovum  midway  in  the  tube  or  at 
its  uterine  extremity  is  very  infrequent.  Hence  for  practical  purposes  ectopic 
gestation  may  mean  an  ampullar  gestation — in  other  words,  a  phenomenon  be- 
ginning at  some  distance  from  the  birth-tract,  and  in  a  region  which  is  the  seat 
of  many  of  the  most  important  gynecological  affections  (ovarian  diseases  and 
tumors,  pus-tubes,  hematomata,  etc.,  etc.).  Gestation  in  one  born  of  a  bicor- 
nate  uterus,  included  by  some  under  ectopic  pregnancy,  is  considered  elsewhere 
(page  500).     Tubal  gestation  occurs  very  rarely  as  a  bilateral  affection. 

A  further  division  as  to  its  site  is  primary  and  secondary.  In  the  former 
the  original  implantation  of  the  ovum  remains  unchanged,  while  in  the  latter 
the  ovum,  through  rupture  of  the  tubes,  or  other  accidents  of  development,  may 
assume  a  new  location. 


362 


PATHOLOGICAL  PREGNANCY. 


•-p^ 


Fig.  490. — Ovarian  Pregnancy. — (Martin*) 


Etiology. — A  great  number  of  conditions  have  been  held  responsible  for  tubal 
gestation,  through  their  theoretical  ability  to  obstruct  the  tube  from  within  or 
compress  it  from  without  and  thus  cause  the  arrest  of  the  ovum  in  situ.     Gyne- 
cologists   enumerate    among' 
intrauterine    causes,    chronic 
salpingitis,  chiefly  of   gonor- 
rheal origin,  neoplasms,  dis- 
locations, and  congenital  mal- 
formations, especially  the  so- 
called  persistence  of  the  fetal 
type    of    tube.       Conditions 
which  compress  the  tube  from 
without  include  pelvic  adhe- 
sions and  tumors.     But  while 
there  is  no  doubt  that  in  indi- 
vidual cases  the  presence  of 
some  one  or  more  of  these  fac- 
tors may  be  recognizable,  the 
great  majority  can  hardly  be 
thus   explained    away.      The 
very  conditions  which  prevent  the  descent  of  the  ovum  only  too   often  cause 
sterility  by  preventing  impregnation.     One  author,  after  a  careful  study  of  the 
causation,  can  see  no  essential  factor  to  explain  the  great  majority  of  cases» 
unless  it  be  the  infantile  tube  which  per- 
mits   of   impregnation    but    favors    the 
arrest  of  the  ovum. 

Pathology. — This  includes  changes 
in  the  ovum,  fetus,  and  uterus.  The  ges- 
tation sac  is  formed  from  the  coats  of  the 
tube- wall.  The  muscular  tissue,  instead 
of  undergoing  hypertrophy,  often  tends 
to  disappear.  The  sac  then  eventually 
consists  of  connective  tissue.  Slight 
peritonitis  often  coexists  and  adhesions 
may  form.  The  attachment  of  the 
ovum  does  not  differ  radically  from  that 
in  normal  uterine  pregnancy.  A  pla- 
centa forms,  but  the  decidual  structures 
are  rudimentary;  so  that  the  chorionic 
vilH  penetrate  readily  into  the  gesta- 
tional sac  as  far  as  the  peritoneum. 
This  phenomenon,  by  favoring  hemor- 
rhage, tends  to  favor  both  abortion  and 
rupture.  In  regard  to  the  history  of  the 
ovum  in  tubal  pregnancy,  it  may  under- 
go early  death  in  the  tube  and  form  a 
mole;  if  rupture  of  the  tube  occurs,  the 
ovum,  expelled  into  the  abdominal  cav- 
ity, usually  perishes,  and  if  very  young  may  be  absorbed.  In  very  exceptional 
cases  it  may  thrive  (secondary  abdominal  pregnancy) ;  if  the  ovum  escapes  into 
the  broad  ligament  (Figs.  492  and  494),  death  with  molar  formation  results.  It  is 
*  "Ueber  Ektop  Schwangerschaft,"  Fig.  i. 


Fig.  491.  —  Interstitial  Pregnancy. 
Right  Wall  of  the  Uterus.  Fourth 
Month. — {Bumm.) 


ECTOPIC  GESTATION. 


363 


Fig.  492. — Intraligamentous  Pregnancy. 
Broad  Ligament. — {Bumm.) 


Left 


commonly  stated  that  in  any  of  these  cases  death  of  the  ovum  may  be  followed 
by  suppuration,  but  it  is  difficult  to  understand  how  this  could  result  under  the 
normal  sterile  conditions  which  should  obtain.  If  the  fetus  dies  only  after 
reaching  an  advanced  stage  of  development,  some  one  of  various  changes  noted 
exceptionally  after  intrauterine  fetal  death  should  develop — calcification,  adipo- 
ceration,  mummification,  etc. 
(page  272).  The  sac  in  these 
conditions  may  remain  quiet 
for  years,  perhaps  eventually 
to  undergo  rupture  into  any 
neighboring  viscus  or  cavity. 
If  the  fetus  does  not  die 
its  tendency  is  toward  poor 
development,  and  the  vari- 
ous deformities  and  diseases 
noted  in  intrauterine  fetuses. 
If  it  reaches  a  "  viable " 
stage,  it  usually  dies  during 
its  extraction  or  soon  after. 
Exceptionally  survival  occurs 
and  the  child  may  be  well 
developed. 

The  collateral  changes  in  the  uterus  during  ectopic  pregnancy  are  of  much 
interest  and  are  considered  under  symptoms  and  diagnosis.  They  are  the  same 
to  a  certain  point  as  those  found  in  normal  pregnancy,  even  to  the  formation 
of  a  decidua  vera  (Fig.  495).     If  the  ovum  dies  these  changes   are  arrested; 

otherwise  they  progress,  al- 
though   at    a   much   slower 
,/''  rate    than    in    intrauterine 

pregnancy.  The  decidua, 
however,  do  not  keep  pace 
with  the  uterus  and  are 
usually  thrown  off  at  an 
early  period  in  bits  or  en 
masse,  simulating  abortion. 
Exceptionally  they  are  re- 
tained to  term,  when  so- 
called  false  labor  occurs. 

Symptoms. — Three  well- 
marked  phases  of  tubal 
pregnancy  may  be  noted 
clinically.  These  are:  (i) 
the  relatively  latent  period 
of  early  gestation  when  rup- 
ture or  abortion  does  not 
supervene;  (2)  the  manifes- 
tations of  ruoture  and  abortion;  (3)  the  period  of  late  gestation  in  cases  which 
have  escaped  rupture. 

/.  Early  Quiescent  Period. — The  quiescence  refers  to  the  ovum  only,  for  the 
patient  may  present  the  general  and  genital  symptoms  of  normal  pregnancy. 
Expulsion  of  decidual  fragments  accompanied  by  hemorrhage  internally  sug- 
gests abortion.     Colicky  pains  in   the  lower  part  of  the  abdomen,  and  uncon- 


\ 


Fig.  493. — Tubal  Pregnancy.  Rupture  of  the  Isth- 
mus OF  THE  Left  Tube  and  Escape  of  the  Ovum 
AND  Blood-clots  into  the  Abdominal  Cavity. — 
(Bumm.) 


364 


PATHOLOGICAL  PREGNANCY. 


nected  with  expulsion  of  decidual  fragments,  are  explained  by  tubal  or  uterine 
contractions.  Such  pains  constitute  about  the  only  local  symptom  proceeding 
from  the  ovum  and  its  vicinity  and  are  said  to  be  quite  common. 

//.  Interruption  of  Pregnancy  by  Rupture  or  Abortion. — Rupture  occurs 
practically  without  warning,  for  any  premonitory  symptoms  are  vague  in  char- 
acter. The  phenomena  are  those  of  shock  or  collapse,  marked  peritoneal  reac- 
tion, -and  at  times  acute  anemia  from  hemorrhage.  The  intensity  of  these 
symptoms  varies  with  the  seat  and  extent  of  rupture  and  the  degree  of  hemor- 
rhage. If  the  hemorrhage  is  copious  enough,  death  usually  soon  supervenes 
unless  laparatomy  can  be  performed;  but  even  after  profuse  bleeding  death  is 
not  inevitable,  for,  as  in  other  similar  conditions,  spontaneous  arrest  may  occur, 
although  secondary  hemorrhage  may  supervene.  A  special  type  of  rupture  is 
that  which  takes  place  between  the  folds  of  the  broad  ligament.     Danger  of 


L^'IIJfcc 


Fig.  494. 


-Broad  Ligament  Pregnancy.- 
{Zweifel.) 


Fig.  495. — Uterine  Decidua  from  a 
Case  of  Extrauterine  Pregnancy. 
— {Zweifel.) 


fatal  hemorrhage  or  collapse  is  here  minimized,  and  the  resulting  hematoma 
causes  extreme  pain  from  distention. 

When  tubal  abortion  (Fig.  496)  occurs  the  accompanying  hemorrhage  into 
the  fetal  sac  may  give  rise  to  subjective  symptoms  which  resemble  those  of  rup- 
ture but  in  a  much  milder  degree.  Abortion  is  now  believed  to  be  the  common 
termination  of  tubal  pregnancy,  and  as  the  escape  of  blood  may  extend  over  a 
long  period,  a  large  hematosalpinx  forms  and  blood  also  drains  into  the  peri- 
toneal cavity  with  formation  of  a  pelvic  hematocele. 

In  tubal  abortion  and  in  mild  degrees  of  rupture  with  fetal  death,  the  con- 
stitutional symptoms  of  impregnation  naturally  disappear. 

Rupture  usually  occurs  during  the  second  and  third  months. 

III.  Latter  Half  of  Gestation. — There  is  not  much  to  be  said  here.  The 
phenomena  chiefly  resemble  those  of  normal  pregnancy,  false  labor  so  called 
setting  in  at  term  or  before;  exceptionally  a  little  later.  Left  to  itself,  the 
fetus  perishes  during  false  labor.  The  uterus  in  ectopic  pregnancy  often  con- 
tinues to  be  the  source  of  apparent  menstruation,  expulsion  of  decidual  frag- 
ments, etc.     This  with  the  asymmetric  appearance  of  the  abdomen,  and  the 


ECTOPIC  GESTATION. 


365 


superficial  position  of  the  fetus,  constitute  the  leading  symptoms  of  the  later 
months  in  tubal  pregnancy. 

Diagnosis. — The  subjective  and  constitutional  phenomena  of  the  different 
stages  of  tubal  gestation  have  been  outlined  in  the  preceding  section.  There 
remains  to  be  considered  the  objective  and  induced  symptoms  upon  which  the 
diagnosis  must  chiefly  be  based. 

During  the  early  quiescent  period  when  there  are  no  pathognomonic  symp- 
toms for  differentiating  ordinary  pregnancy,  an  enlarged  Fallopian  tube  may  be 
made  out  by  careful  bimanual  examination ;  and  the  decidual  character  of  the 
fragments  which  escape  from  the  uterus  in  some  cases  may  be  recognized  by 
the  microscope.  Naturally  the  fear  of  disturbing  a  normal  pregnancy  and  of 
rupturing  an  impregnated  tube  militates  against  a  vigorous  physical  examina- 
tion. As  a  matter  of  fact,  a  diagnosis  is  seldom  made  during  the  early  months; 
only  after  an  early  termination  of  pregnancy  by  rupture  or  abortion,  or  after 
the  cumulation  of  symptoms  of   an  atypical  gestation,  is  the   condition  usually 


(  mfm^"\ 


'^> 


Fig.  496. — Tubal  Abortion,   Ovum   being  Extruded   through   the   Fimbriated  Ex- 
tremity OF  THE  Tube. — {Kelly.)    X  i. 


recognized.  In  a  suspected  case  a  history  of  prolonged  sterility  is  of  some 
collateral  value. 

When  rupture  or  abortion  has  evidently  occurred,  bimanual  examination 
reveals  the  presence  of  blood  in  Douglas's  sac,  in  addition  to  the  enlarged  preg- 
nant tube,  the  size  of  which  may  be  abnormally  increased  by  the  supervention 
of  a  hematosalpinx.  Naturally  in  profuse  hemorrhage  with  impending  death 
the  diagnosis  is  established  by  the  resulting  laparotomy.  In  hemorrhage  into 
the  folds  of  the  broad  ligament  the  peculiar  character  and  seat  of  the  tumor 
are  recognized  by  palpation  through  the  vagina  and  rectum  and  from  without. 

In  the  latter  half  of  gestation  diagnosis  is  made  by  mapping  out  the  sac  and 
the  uterus  itself,  which  while  enlarged  seldom  exceeds  even  at  term  the  size  of 
the  normal  impregnated  organ  at  four  months.  The  abnormal  location  of  the 
fetus  is  made  out  by  auscultation  of  heart-sounds,  ballottement,  and  in  general 
the  measures  in  use  for  determining  the  fetal  position  in  normal  pregnancy. 
(For  the  complications  of  normal  with  ectopic  pregnancy  see  page  136.) 

Treatment. — There  is  no  medical  treatment  for  ectopic  pregnancy,  nor  any 
palliative  or  temporizing  management;  for  the  right  of  the  child  to  be  born 


366  PATHOLOGICAL  PREGNANCY. 

alive  does  not  enter  into  the  question.  During  the  early  quiescent  period  when 
the  condition  is  strongly  suspected,  or  when,  during  laparotomy,  etc.,  the  con- 
dition is  accidentally  discovered,  the  tube  should  be  extirpated.  The  ovary  may 
be  let  alone,  treated  conservatively,  or  extirpated  along  with  the  tube,  accord- 
ing to  its  condition. 

After  the  diagnosis  of  rupture  or  abortion  is  made,  a  radical  operation  is  at 
once  indicated,  irrespective  of  the  severity  of  the  hemorrhage.  When  great 
loss  of  blood  has  occurred,  or  is  still  taking  place,  saline  infusion  (intravenous) 
is  begun  with  the  operation  and  continued  during  and  after.  In  certain  cases 
in  which  hemorrhage  appears  to  have  ceased,  it  is  of  some  advantage  to  allow 
the  patient  to  recover  from  slow  collapse  before  anesthetizing.  It  is  well  to 
postpone  saline  infusion,  however,  until  the  moment  of  operating.  If  the 
patient  has  naturally  rallied  from  the  hemorrhage  and  shock  to  such  an  extent 
that  she  is  out  of  immediate  danger,  it  is  still  best  to  interpose  at  once  lest 
secondary  hemorrhage  occur. 

Tubal  Abortion. — Laparotomy  is  performed  in  the  Trendelenburg  position. 
The  tube  is  first  clamped  and  then  ligated  and  both  ends  are  removed.  Escaped 
blood,  clots,  fetal  tissue,  etc.,  in  the  peritoneal  cavity  should  be  removed  by 
sponging.  In  hematoma  of  the  broad  ligament  the  latter  must  be  incised  and 
evacuated,  the  wound  being  closed  with  buried  sutures. 

After  gestation  has  progressed  beyond  the  period  of  rupture  and  abortion, 
diagnosis  must  be  followed  by  extirpation  of  the  sac  as  a  whole,  or  of  its  con- 
tents. The  first  is  practicable  only  up  to  a  certain  period,  viz.,  before  the 
establishment  of  the  placental  condition,  or  prior  to  the  end  of  the  fourth 
month.  This  is  essentially  readily  accomplished  by  the  ordinary  operation  of 
salpingectomy  with  additional  precaution  as  to  hemostasis. 

After  this  period  the  danger  of  hemorrhage  is  too  great  to  permit  of  attempt- 
ing the  removal  of  the  sac  en  masse  and  a  modified  operation  is  recommended. 
The  sac  is  incised  and  the  fetus  removed,  the  cord  being  afterward  ligated  close 
to  the  placenta.  The  incision  is  then  sutured  to  the  external  wound  and  packed 
with  aseptic  gauze,  after  careful  cleansing  with  the  saline  solution.  A  glass 
drain  replaces  the  packing  at  the  end  of  forty-eight  hours,  and  remains  until  the 
complete  obliteration  of  the  sac.  During  this  period  the  placental  circulation 
is  slowly  arrested  and  the  placenta  itself  generally  comes  away  in  fragments. 
If  the  fetus  is  dead,  either  recently  or  after  a  long  interval,  this  precaution  is 
not  necessary,  as  the  entire  contents  of  the  sac  may  be  removed,  including  all 
fetal  tissue. 


CORNUAL  PREGNANCY. 


367 


XXI.   PREGNANCY  IN   ONE   HORN   OF  A  UTERUS  BICORNIS 
OR    UNICORNIS;   CORNUAL   PREGNANCY. 

Cornual  pregnancy  is  the  development  of  an  ovum  in  one  horn  of  a  two- 
homed  uterus  or  in  one  side  of  a  double  uterus  (Figs.  497  and  498)-  Fortun- 
ately the  condition  is  rare,  for  women  with  malformations  of  the  uterus  are 


Fig.  497. — Pregnancy  in  the  Rudimentary  Horn  of  a  Uterus  Unicornis.  The  rudi- 
mentary horn  is  shut  off  from  the  uterine  cavity.  The  corpus  luteum  was  found  in 
the  ovary  of  the  opposite  side;  hence  intraperitoneal  transmigration  of  the  ovum  oc- 
curred.— (Howard  Kelly.) 


Fig.  4q8. — Uterus  Duplex  Bicornis,  with 
A  Vagina  Septa.  The  right  uterus  con- 
tained the  product  of  conception  and  was 
6|  inches  (17  cm.)  long;  the  left  uterus  was 
filled  with  decidua  alone  and  was  4f  inches 
(12  cm.)  long,  r.  Right  uterus  ;  v,  right 
vagina;  i,  intervaginal  septum. — (Nagel.*) 


Fig.  499. — Pregnancy  with  a  Uterus 
Duplex. t  The  unimpregnated  part 
caused  an  obstruction  to  labor. 


*  Veit's  "Handbuch  d.  Gyn.,"  Bd.  i,  Fig.  119. 
t  "Zeitsch.  f.  Geb.  u.  Gyn.,"  Bd.  xiv,  S.  169. 


368 


PATHOLOGICAL  PREGNANCY. 


subject  to  more  complications  during  both  pregnancy  and  labor  than  when 
the  uterus  is  normal;  they  are  more  easily  infected  and  fatal  terminations  are 
common.  If  the  horn  is  well  developed,  delivery  may  be  normal;  but  if  the 
horn  is  rudimentary  and  there  is  no  normal  communication  with  the  lower 
genital  tract,  the  condition  resulting  is  markedly  like  ectopic  pregnancy  (Figs. 
501  and  502).  The  symptoms,  course,  and  treatment  are  then  practically  the 
same  as  in  ectopic  pregnancy.     Kehrer,  who  collected  and  analvzed  82  cases 


Fig.    500. — Pregnancy    in    an    Undeveloped 
Horn  of  a  Uterus  Bicornis. — (Werth.*) 


Rd.Liyame> 


Fig.  501. — Pregnancy  in  a  Rudi- 
mentary Horn  of  a  Uterus, 
SHOWING  the  Relation  of  the 
Round  Ligament  to  the  Gesta- 
tion Sac.  The  Sac  is  Inside  of 
THE  Round  Ligament. — {Dakin.) 


Fig.  502. — Relations  op  the  Sac  of 
A  Tubal  Pregnancy  to  the  Round 
Ligament.  The  Sac  is  Outside  of 
THE  Round  Ligament. — {Dakin.) 


from  literature  in  1900,  states  that  expectancy  is  never  indicated.  Intervention 
should  always  be  by  Caesarean  section  after  the  thirty-second  week.  In  Kehrer's 
study  all  the  cases  of  labor  in  uterus  duplex  (Fig.  499)  are  recorded.  The  great 
majority  are  divided  about  equally  between  uterus  unicornis  bicollis  and 
uterus  bicornis  unicollis  (Fig.  497).  A  few  cases  occurred  in  uterus  bicornis 
duplex  (Fig.  499)  and  uterus  septus  bilocularis,  but  none  whatever  in  any 
other  varieties. 


XXII.   MISSED    LABOR. 

At  full  term  ineffectual  labor  sets  in,  subsides,  and  the  uterus  remains  un- 
emptied  for  months  or  even  years;  occasionally  simple  prolongation  of  preg- 
nancy, without  any  onset  of  labor  occurs.  A  like  condition  is  that  of 
"missed  abortion,"  when  the  fetus  dies  in  the  early  months  of  gestation  and 
remains  in  the  uterus  for  weeks  or  months. 

Etiology. — This  is  obscure ;  some  variety  of  obstructed  labor  is  usually  present 
such  as  tumors  of  the  soft  parts,  exostoses  or  tumors  of  the  bony  pelvis,  con- 

*  "Arch.  f.  Gvn.,"  Bd.  xvii,  S.  281. 


SUDDEN  DEATH  IN  PREGNANCY.  369 

tractfid  pelvis,  cancer  of  the  uterus,  cicatricial  bands  of  the  cervix  or  vagina. 
The  possibility  of  ectopic  gestation,  or  of  pregnancy  in  one  horn  of  a  bicornu- 
ate  or  unicornuate  uterus,  must  be  remembered  (see  pages  361,  367). 

Terminations. — The  fetus  always  dies,  and  one  of  the  following  changes 
occurs:  (i)  maceration  of  soft  parts  and  prolonged  discharge  from  the  cervix, 
with  retention  of  the  bones  (page  305);  (2)  ulceration  through  the  uterine  wall 
into  the  vagina,  rectum,  or  abdominal  cavity;  (3)  septic  metritis  and  fatal 
septicemia;  (4)  mummification;  (5)  calcification;  (6)  adipoceration ;  (7)  putre- 
faction.    (Compare  Death  of  the  Fetus,  page  272.) 

Treatment.— No  pregnancy  should  be  allowed  to  continue  more  than  two 
weeks  past  the  normal  period  of  gestation,  without  a  thorough  examination 
as  to  the  cause,  with  the  aid  of  an  anesthetic,  if  necessary.  The  treatment 
will  depend  upon  the  findings  in  this  examination.  If  pregnancy  be  normal, 
labor  should  be  at  once  induced;  if  ectopic  or  cornual,  treatment  should  be 
along  the  lines  laid  down  for  those  conditions.  In  cases  in  which  weeks  or  months 
have  elapsed  and  maceration  or  putrefaction  of  the  fetus  has  occurred,  in 
intrauterine  pregnancy,  the  uterus  should  be  emptied  with  all  antiseptic  pre- 
cautions, and  in  cases  of  uterine  sepsis  or  perforation,  hysterectomy  is  advisable. 


XXIII.   SUDDEN    DEATH    IN    PREGNANCY. 

Sudden  death,  directly  attributable  to  pregnancy,  appears,  with  few  excep- 
tions, to  be  an  impossibility;  although  the  state  of  gestation  is  naturally  able 
to  influence  unfavorably  the  prognosis  of  many  serious  affections,  and  thus  to 
bring  about  sudden  death  indirectly,  as  in  the  case  of  cardiac  valvular  disease. 
Further,  there  are  sudden  affections  which,  while  not  peculiar  to  pregnancy, 
appear  to  be  determined  by  the  latter  and  may  lead  up  to  sudden  death  (acute 
yellow  atrophy  of  the  liver,  impetigo  herpetiformis).  Finally,  pregnancy  does 
not  appear  to  afford  any  immunity  to  sudden  deaths  from  common  causes, 
and  the  pregnant  woman  succumbs  to  apoplexy  and  the  like,  just  as  does  the 
non-pregnant.  Sudden  death,  absolutely  referable  to  the  pregnant  state, 
could  come  only  from  eclampsia  before  delivery;  from  some  mechanical  result 
of  the  crowding  of  the  viscera  by  the  enlarged  uterus  (internal  intestinal  strangu- 
lation, etc.);  from  attempts  at  abortion,  including  the  use  of  poisons;  and, 
finally,  from  operative  intervention. 


XXIV.    INJURIES  TO   AND   OPERATIONS   UPON    PREGNANT 

WOMEN. 

Injuries  and  Accidents. — Severe  injuries  do  not  necessarily  result  in  a  pre- 
mature interruption  of  pregnancy.  The  more  common  are  those  which  cause 
a  rupture  of  an  enlarged  blood-vessel  of  the  external  genitals  or  of  the  lower 
extremities.  In  a  distended  and  varicose  condition  of  the  vessels  of  the 
vulva,  the  rupture  of  these  vessels,  owing  to  a  fall  from  a  bicycle,  has  resulted 
in  almost  fatal  hemorrhage.  In  a  case  in  private  practice,  I  almost  lost  a 
patient  from  this  cause;  pregnancy  was  not  disturbed.  Many  instances  are 
recorded  of  the  mother  sustaining  severe  injuries  by  blows  and  falls,  without 
pregnancy  being  interrupted.  The  abdomen  itself  has  been  torn  open,  and 
the  fetus  has  even  sustained  fractures  and  traumata,  and  pregnancy  has  con- 
24 


370  PATHOLOGICAL  PREGNANCY. 

tinued.  Extensive  general  bums,  and  severe  local  bruises  and  injuries  of 
the  vulva  and  pelvic  floor,  have  not  interfered  with  pregnancy.  Spontaneous 
rupture  of  the  uterus  is  one  of  the  rarest  accidents,  and  may  be  due  to  trau- 
matism, overdistention,  a  previous  Caesarean  section,  or  chronic  inflammation. 
Again,  traumatism  may  be  an  exciting  cause  of  rupture,  in  the  presence  of 
hydramnios,  chronic  inflammation  of  the  uterus,  or  weakening  of  the  uterine 
walls  by  a  previous  hysterectomy. 

Penetrating  Wounds  of  the  Gravid  Uterus. — This  lesion  is  of  very  rare  occur- 
rence. In  1899  *  Estor  and  Pruech  could  find  notes  of  but  40  cases  in  literature. 
The  wounds  were  inflicted  by  cutting  or  pointed  instruments,  projectiles,  the 
horns  of  animals,  etc.,  and  could  be  divided  into  incomplete,  complete,  and 
complicated.  In  the  first-named  the  uterine  wall  was  not  completely  pene- 
trated. Complete  penetration  has  been  extensive  enough  to  permit  the  escape 
of  the  cord  or  even  the  fetus  itself.  In  the  complicated  type  other  abdominal 
viscera  were  also  wounded.  The  symptoms  are  those  of  shock  and  hemor- 
rhage with  pain,  escape  of  amniotic  fluid,  and  prolapse  of  some  of  the  contents 
of  the  uterus.  Peritonitis  resulted  in  a  certain  proportion  of  cases.  About 
25  per  cent,  of  the  cases  were  fatal  from  shock,  hemorrhage,  or  peritonitis. 
The  complicated  •  wounds  have  necessarily  a  graver  prognosis.  Laparotomy 
may  be  necessary  for  diagnosis,  and  certainly  will  be  required  for  rational 
treatment  with  or  without  hysterectomy. 

Operations. — Surgical  operations  upon  pregnant  women  are  not  only  justi- 
fiable, but  demanded,  when  delay  until  after  confinement  would  seriously 
jeopardize  the  health  or  life  of  the  patient.  Under  ordinary  circumstances  there 
is  little  danger  of  interrupting  the  pregnancy.  Women  of  great  nervous  irrita- 
bility will  sometimes  prove  the  exception  to  the  rule.  The  irritation  produced 
by  ulceration  at  the  root  of  a  tooth  is  usually  more  liable  to  interrupt  a  preg- 
nancy than  the  administration  of  nitrous  oxide  gas  and  the  removal  of  the  tooth, 
or  the  establishment  of  free  drainage.  The  author  has  repeatedly  had  gas 
administered  to  patients  for  this  purpose,  and  has  never  seen  any  bad  results. 
Fibroid  tumors,  ovarian  cysts,  and  the  appendix  are  now  frequently  removed, 
without  interrupting  pregnancy,  and  for  numerous  other  causes  the  abdomen 
has  been  opened  and  pregnancy  has  continued.  Operations  should  not  be  per- 
formed at  a  period  corresponding  with  the  menstrual  epoch,  as  abortion  is  then 
more  apt  to  occur.  For  the  same  reason,  it  will  be  well  to  avoid  the  third,  fourth, 
and  eighth  months.  My  opinion  is  that  anesthetics  in  pregnancy  are  rather 
favorable  than  otherwise  in  their  influence,  when  thev  decrease  reflex  irritation. 


XXV.     PREGNANCY    AFTER  OPERATIONS    INVOLVING    THE 
GENITALS;  PREGNANCY  AFTER  VENTROFIXATION  AND 

VENTROSUSPENSION. 

See  Pathology  of  Labor,  Part  V. 


XXVI.    FEVER   OF   PREGNANCY. 

This   peculiar   affection   has   been   described   by   a   number   of   authorities, 
including  Tarnier  and  Ahlfeld.     It  occurs  in  two  types,  acute  and  subacute 

*  "  Rev.  de  gynecol.,"  Nov.,  Dec,  1899, 


METRORRHAGIA    OF  PREGNANCY. 


371 


or  chronic,  which  differ  radically,  and  are  held  to  be  entirely  separate  condi- 
tions. Acute  fever  of  pregnancy  resembles  such  conditions  as  typhoid  fever, 
septicemia,  and  acute  miliary  tuberculosis.  Chronic  fever  of  pregnancy  appears 
to  be  a  neurosis,  with  participation  of  the  heat-center.  Clinically  it  has  been 
likened  to  a  confirmed  phthisis.  From  the  facts  that  these  febrile  affections 
supervene  without  the  least  apparent  cause,  and  subside  immediately  after 
the  uterus  is  evacuated,  they  have  received  the  designation  "fever  of  preg- 
nancy." On  account  of  the  serious  character  of  the  symptoms,  abortion  has 
been  performed  a  number  of  times.  Had  the  correct  diagnosis  been  made, 
no  intervention  would  have  resulted.  Kleinwachter  is  opposed  to  the  use 
of  the  term  "fever  of  pregnancy,"  or  including  the  condition  among  the 
indications  for  terminating  pregnancy. 


XXVI I.  THE  METRORRHAGIA  OF  PREGNANCY;  ANTE-PARTUM 

HEMORRHAGE. 

A  discharge  of  blood  from  the  vagina  during  pregnancy  naturally  suggests 
threatened  or  inevitable  abortion  (Fig.  504),  or  placenta  prasvia,  and  should 


Fig.  503. — The  Metrorrhagia  of  Preg- 
nancy. Menstruation  Occurring  in 
THE  Early  Weeks. 


Fig.  504. — The  Metrorrhagia  of  Preg- 
nancy. Hemorrhage  caused  by  the  sep- 
aration of  the  decidua  vera  from  the  uter- 
ine wall  in  threatened  or  inevitable  early 
abortion. 


always  receive  careful  attention.  There  are  various  other  causes  of  hemorrhage, 
however,  which  should  not  be  forgotten.  They  will  be  discussed  here  chiefly 
with  reference  to  the  diagnosis;  the  treatment,  when  of  obstetric  importance, 
being  considered  elsewhere,  (i)  In  cervical  endometritis,  or  cervical  catarrh,  the 
vaginal  mucus  may  be  stained  with  blood,  but  the  amount  is  usually  slight;  the 
cervix  will  be  found  larger  than  normal,  with  perhaps  pouting  of  the  lips,  erosions 
of  the  mucous  membrane,  and  follicular  degeneration ;  the  outer  lips  of  the  ex- 


372 


PATHOLOGICAL  PREGNANCY. 


temal  os  having  a  velvety  feeling.  There  is  follicular  degeneration,  and  little 
nodules,  like  shot,  can  be  felt  by  the  examining  finger.  (2)  In  eroded  cervix, 
or  cervical  erosions  so  called,  there  are  patches  of  bright  red,  granular  mucous 
membrane,  which  were  formerly  erroneously  supposed  to  be  ulcers ;  they  readily 
bleed  upon  pressure.  (3)  With  lacerated  and  eroded  cervix,  the  infection  of  a 
cervical  tear  is  a  common  cause  of  cervical  endometritis.  In  these  cases  there 
will  be  considerable  cervical  hypertrophy,  with  the  other  evidences  of  cervical 
inflammation.     (4)  Persistence  of  menstruation  is  a  rare  condition.     In  many 

of  the  recorded  cases,  the  hemorrhage 
has  been  probably  due  to  placenta 
praevia  or  other  causes.  The  diagnosis 
must  rest  on  the  monthly  occurrence 
of  the  flow  and  upon  the  exclusion  of 
other  sources  of  hemorrhage  (Fig. 
5°3)-  (5)  Hemorrhoids  of  the  vagina, 
ostium  vaginae,  or  vulva  have  already 
been  discussed.  In  rare  instances,  and 
usually  as  the  result  of  traumatism, 
rupture  may  occur,  giving  rise  to 
severe  hemorrhage,  which  requires 
suture.  The  diagnosis  is  made  by  in- 
spection. ( 6)  Hemorrhage  may  be  due 
to  separation  of  a  placenta  prcevia,  or 
of  a  normally  situated  placenta  (see 
pages  214  and  224)  (Fig.  505).  (7)  An 
iniracervical  polyp  sometimes  occurs 
as  a  complication  of  gestation,  and 
causes  persistent  hemorrhage;  the 
diagnosis  is  made  by  inspection.  If 
there  is  much  protrusion  of  the  poly- 
pus the  diagnosis  will  not  be  difficult. 
In  some  cases,  however,  it  is  very  likely 
to  be  confounded  with  abortion,  the 
polypus  being  mistaken  for  the  intact 
ovum.  The  history  of  the  case  before 
pregnancy  may  be  of  assistance.  (8) 
Cancer  of  the  cervix  may  be  a  cause  of 
hemorrhage  during  pregnancy,  and 
has  been  mistaken  for  placenta  prae- 
via. The  diagnosis  will  rest  upon  the 
characteristic  cauliflower  appearance, 
when  it  is  present ;  upon  the  fetid  dis- 
charge; and  upon  the  exclusion  of  other  sources  of  hemorrhage,  such  as  placenta 
praevia,  cervical  erosions,  and  cervical  polypus.  The  diagnosis  must,  of  course,  be 
confirmed  by  microscopic  examination.  ( 9)  Malignant  disease  of  the  vagina  is  not 
common,  and  when  it  does  occur  is  usually  secondary  to  cancer  of  the  cervix. 
Hemorrhage  and  a  foul-smelling  discharge  are  common  symptoms.  There  may 
be  a  papillary  swelling  of  the  posterior  wall,  or  the  vaginal  walls  may  be  generally 
infiltrated  and  the  vagina  constricted.  The  inguinal  glands  are  usually  infil- 
trated. (10)  Apoplexy  of  the  placenta  has  already  been  discussed;  if  slight 
hemorrhage  occurs  and  placental  apoplexy  is  suspected,  the  treatment  is,  of 
course,  that  of  threatened  abortion  (see  page  357). 


Fig.  505. — The  Metrorrhagia  of  Preg- 
nancy. Internal  concealed  hemorrhage 
from  the  separation  of  a  normally  situated 
placenta,  and  also  hemorrhage  from  the 
separation  of  a  central  placenta  praevia. 


PART    FOUR. 
Physiological   Labor* 


I.  THE    PASSAGES.     I.  The   Bony    Pelvis.     (Page   375.)     (I)   The   Bones. 

(2)  The  Pelvic  Joints.  (3)  Internal  Surface  of  Pelvis.  (4)  The  False  Pelvis. 
(5)  The  True  Pelvis.  (6)  The  Pelvic  Inlet.  (7)  The  Pelvic  Cavity.  (8) 
Pelvic  Outlet.  (9)  Table  of  Pelvic  Measurements,  (a)  External;  (b)  In- 
ternal. (10)  Pelvic  Planes,  (a)  Inlet ;  (b)  Cavity ;  (c)  Outlet.  (11)  Pelvic 
Axes,  (a)  Inlet;  (b)  Cavity;  (c)  Outlet.  (12)  Comparison  of  Different 
Pelvic  Diameters,  Circumferences,  Planes  and  Angles.  (13)  Factors  In- 
fluencing Size  and  Shape  of  Pelvis:  (1)  Individual;  (2)  Sex;  (3)  Age,  Infan- 
tile and  Antepubic.  (14)  Functions.  2.  The  SOFT  Tissues  OF  THE  Pelvis. 
(Page  393.)  Soft  Parts.  (1)  Muscles.  Psoas  Majus,  Psoas  Parvus,  Uia- 
cus,  Levator  Ani,  Pyriformis,  Coccygeus,  Obturator  Internus,  Bulbo- 
cavernosus.  (2)  Ligaments,  (a)  Great  Sacro-sciatic ;  (b)  Small  Sacro- 
sciatic.     (3)   Pelvic  Cellular  Tissue.     (4)   Blood-vessels  and    Lymphatics. 

(5)  Nerves.     3.  The  Parturient  Tract.     (Page  400.) 

II.  THE  FETUS.  1.  The  Fetal  Head.  (Page  408.)  (1)  Introduction.  (2) 
Regions  and  Protuberances.     (3)   Bones.     (4)  Sutures.     (5)  Fontanelles. 

(6)  Movements  upon  Spinal  Column.  (7)  Complete  Flexion.  (8)  Incom- 
plete Flexion.  (9)  Complete  Extension.  (10)  Incomplete  Extension.  (11) 
Rotation.  (12)  Moulding.  (13)  Diameters.  (14)  Planes  and  Circum- 
ferences. 2.  The  Fetal  Trunk.  (Page  417.)  (1)  Shape.  (2)  Measure= 
ments.  3.  Attitude  or  Posture.  (Page  420.)  Fetal  Ovoid  or  Ellipse. 
4.  Presentation.  (Page  421.)  (I)  Shape  of  Uterine  Cavity.  (2)  Shape 
of  Fetal  Ellipse.  (3)  Uterine  Contractions.  (4)  Mobility  of  Head.  (5) 
Direction  of  Uterine  Force.  (6)  Gravity.  (7)  Reflexion.  5.  Position. 
(Page  425.)  (1)  Flattened  Shape  of  Fetal  Ovoid.  (2)  Shape  of  Uterine 
Cavity.  (3)  Axial=torsion  of  Uterus.  (4)  Shortening  of  Left  Oblique  Di- 
ameter of  Pelvis  by  Sigmoid  and  Rectum.  (5)  Diminution  of  Transverse 
Diameter  by  Muscles.     (6)  Greater  Roominess  of  Right  Oblique  Diameter. 

III.  EXPELLING  FORCES.    (Page  428.)     1.  Voluntary  or  Auxiliary  Forces. 

2.  Involuntary  Forces  or  Uterine  Contractions.  3.  Strength  of 
Uterine  Contractions. 

IV.  ETIOLOGY  OF  LABOR.     (Page  431.) 

V.  THE  STAGES  OF  LABOR.  (Page  432.)  1.  Preparatory  Stage.  (I) 
Sinking  of  Uterus.  (2)  Gradual  Shortening  of  Cervix  and  Dilatation.  (3) 
False  or  Spurious  Labor  Pains.  2.  First  Stage  or  Stage  of  Dilatation 
or  DiLATABiLiTY.  (1)  True  Uterine  Contractions.  (2)  Muco-sanguineous 
Discharge.  (3)  Mechanism  of  Cervical  Dilatation.  (4)  Formation  of  Caput 
Succedaneum.  3,  Second  Stage  or  Stage  of  Expulsion.  (I)  Charac- 
teristic Uterine  Contractions.  (2)  Use  of  Voluntary  Forces.  (3)  Descent 
of  Presenting  Part.  (4)  Dilatation  of  Vagina.  (5)  Dilatation  of  Vulva. 
(6)  Expulsion  of  Fetus.  4.  Third  Stage  or  Stage  of  Placental  Delivery. 
(1)  Characteristic  Uterine  Contractions.  (2)  Control  of  Hemorrhage.  (3) 
Separation  of  Placenta.     (4)  Expulsion  of  Placenta. 

VI.  THE  MECHANISM  OF  LABOR.     (Page  440.)     1.  Definition.    2.  Import^ 
ance.     3.   Six    Stages.      (1)    Moulding.     (2)    Engagement   and    Descent. 

(3)  Rotation  of  the  First  Part  of  the  Fetal  Ellipse.  (4)  Expulsion  of  the 
First  Part  of  the  Fetal  Ellipse.  (5)  Rotation  of  the  Second  Part  of  the 
Fetal  Ellipse.     (6)   Expulsion  of  the  Second  Part  of  the  Fetal  Ellipse. 

VII.  THE  DURATION  OF  LABOR.     (Page  448.) 

VIII.  LIVE  BIRTH.     (Page  448.) 

IX.  FEIGNED  DELIVERY.     (Page  449.) 


X.  UNCONSCIOUS  DELIVERY.     (Page  449.) 

XI.  VERTEX  PRESENTATIONS.  (Page  450.)  I.  Definition.  2.  Frequency. 
3.  Etiology.  4.  Positions  and  Relative  Frequency.  5.  Mechanism. 
(1)  Flexion  and  Moulding.  Caput  Succedaneum.  (2)  Engagement  and 
Descent.  (3)  Anterior  Rotation  of  Occiput.  (4)  Extension  and  Expulsion 
of  the  Head.  (5)  Rotation  of  the  Trunk  and  Restitution  of  the  Head. 
(6)  Expulsion  of  the  Trunk.    6.  Diagnosis.     7.  Prognosis. 

XII.  MANAGEMENT  OF  LABOR.  (Page  463.)  1.  Introduction.  Prophylaxis 
in  Obstetrics.  Hygiene  of  Pregnancy.  Response  to  Summons.  2.  Pre- 
liminary Preparations.  (1)  The  Obstetric  Outfit.  (2)  Mother's  Outfit. 
(3)  Baby's  Outfit.  (4)  Physician's  Obstetric  Bag.  (5)  The  Obstetric  Nurse. 
Rules.  (6)  The  Lying=in  Room.  (7)  The  Labor  Bed.  (a)  Permanent  Bed ; 
(b)  Temporary  Bed ;  (c)  Arrangement  of  Double  Bed.  3.  Preparation 
OF  THE  Physician,  (l)  Previous  Septic  Contact.  Gloves.  (2)  Personal 
Cleanliness.  (3)  Obstetric  Asepsis.  (4)  Operating  Suit.  (5)  Hand  Lubri- 
cants. 4.  Preparation  of  Patient.  (1)  Enema.  (2)  Pubic  Hair.  (3) 
Antepartum  Bath.  Local  Antisepsis.  (4)  Antepartum  Douche.  (5)  Vulvar 
Dressing.  5.  The  Examination  of  Labor.  (1)  Posture  of  Patient.  (2) 
Obstetric  Prognosis.  6.  Management  of  the  First  Stage.  (1)  Posture 
of  Patient.  (2)  Presence  of  Physician.  (3)  Attention  to  Bladder  and  Rec- 
tum. (4)  Food,  Drink,  Sleep.  (5)  Use  of  Voluntary  Forces.  (6)  Care  of 
Membranes.  (7)  Anesthesia.  (8)  Repetition  of  Vaginal  Examinations. 
7.  Management  of  Second  Stage.  (1)  Posture  of  Patient.  (2)  Presence 
of  Physician.  (3)  Attention  to  Bladder  and  Rectum.  (4)  Food,  Drink, 
Sleep.  (5)  Use  of  Voluntary  Forces.  (6)  Care  of  Membranes.  (7)  Anes- 
thesia. (8)  Repetition  of  Vaginal  Examinations,  (9)  Perineal  Protection. 
(10)  Cleansing  of  Eyes  and  Mouth.  (11)  Care  of  Cord  about  Neck.  (12) 
Shoulder  Delivery.  (13)  Delivery  of  Trunk.  (14)  Following  down  Fundus. 
(15)  Posture  of  Child  in  Bed.  (16)  Establishment  of  Respiration.  (17) 
Ligation  of  Cord.  (18)  Care  of  Cord.  (19)  Silver  Solution  for  Eyes.  (20) 
Handling  Child.  (21)  Protection  of  Child  from  Cold.  (22)  Prevention  of 
Hemorrhage.  (23)  Inspection  and  Repair  of  Perineum.  9.  Management 
OF  Third  Stage.  (1)  Prevention  of  Hemorrhage.  (2)  Temporary  Vulvar 
Dressing.  (3)  Delivery  of  the  Placenta.  (4)  Postpartum  Douche.  (5) 
Ergot.  (6)  Inspection  and  Repair  of  Perineum.  (7)  Cleansing  of  Patient 
and  Bed.  (8)  Abdominal  Binder.  (9)  Permanent  Vulvar  Dressing.  (10) 
Nourishment.     Rest.     Sleep.     (11)  The  Physician's  Hour. 


Labor  is  the  physiological  end  of  pregnancy,  and  may  be  defined  as  the  pro- 
cess by  which  the  fetus  and  its  appendages  are  separated  from  the  mother. 
All  labors  are  classified  as  either  normal  or  abnormal,  or,  as  they  are  here  desig- 
nated, physiological  and  pathological  labors.  Normal  or  physiological  labor 
is  the  delivery  of  a  living  child  with  the  vertex  presenting,  by  the  natural  forces, 
.and  without  complication  in  any  of  the  three  stages.  Should  the  fetus  be 
still-born,  its  death  having  occurred  either  just  previous  to  or  during  the  labor, 
but  not  being  directly  due  to  the  labor,  the  labor  would  still  be  within  the  limits 
of  normal.  Vertex  presentation  is  the  most  frequent,  it  gives  the  lowest  mor- 
tality rate,  and  labor  is  more  easily  and  quickly  terminated  by  this  than  by 
any  other  presentation.  The  three  factors  concerned  in  any  variety  of  labor 
are:  (i)  the  passages;  (2)  the  fetus;  (3)  the  forces. 


I.  THE  PASSAGES. 

I.  THE    BONY    PELVIS. 

Introduction  and  Definitions. — A  knowledge  of  the  female  bony  pelvis 
is  the  very  alphabet  of  obstetric  science  and  the  foundation  of  obstetric  art. 
This  structure  is  most  important,  since  it  is  from  the  disproportion  between 
its  size  and  that  of  the  fetus  or  from  its  abnormal  shape  that  many  of  the  diffi- 
culties during  labor  arise.  The  derivation  of  the  term  is  from  the  Greek  word 
T^sU'^,  "a  bowl,"  from  its  fancied  resemblance  to  that  ancient  utensil  once 
used  by  barbers;  or  it  may  be  because  it  plays  the  part  of  a  reservoir  for  certain 
temporary  secretions.  It  is  that  part  of  the  trunk  which  forms  the  lower 
abdom'inal  boundary,  and  in  the  adult  it  is  situated  near  the  middle  of  the 
body.  It  transmits  to  the  lower  extremities  the  weight  which  it  receives  from 
the  head  and  the  rest  of  the  trunk;  it  is  supported  anteriorly  by  the  femora; 
it  is  open  above  and  below  and  is  a  bony,  irregular,  roomy,  and  conoidal  shaped 
cavity  or  canal.  The  anatomical  pelvis  is  composed  of  four  bones:  the  two 
ossa  innominata,  the  sacrum,  and  the  coccyx.  The  obstetric  pelvis  includes, 
besides  these  bones  just  mentioned,  the  last  lumbar  vertebra.  This  description 
designates  the  static  pelvis,  but  there  are  other  parts  to  be  considered  in 
the  dynamic  pelvis — that  seen  in  the  living  subject  and  in  labor.  These  are 
the  soft  parts  which  form  its  floor  and  extend  the  parturient  canal.  It  will  be 
seen  from  this  statement  that  the  obstetrician  must  recognize  and  be  familiar 
with  two  pelves,  the  one  bony  and  stable,  the  other  soft  and  pliable.  The 
former  is  passive,  the  latter  active.  The  most  important  parts  of  the  pelvis, 
obstetrically,  are  the  inlet  and  the  outlet. 

The  Bones  (Ossa  Innominata,  Sacrum,  Coccyx). — The  anterior  and  lateral 
walls  of  the  pelvis  are  formed  by  the  ossa  innominata.  Each  os  innominatumor 
hip-bone  is  shaped  like  a  stretched-out  quadrangle,  constricted  and  twisted 
in  the  middle,  by  which  means  the  two  parts  of  the  bone  are  brought  into  differ- 
ent planes  (Fig.   506).     The  hip-bone  is  composed  of:  (i)  the   ilium;    (2)  the 

375 


376 


PHYSIOLOGICAL  LABOR. 


ischium;  (3)  the  pubis.  It  is  not  till  the  eighteenth  or  twentieth  year  that 
the  several  parts  of  the  acetabulum  are  firmly  joined.  A  faint  white  line  marks 
the  junctions.  The  sacrum  forms  the  larger  part  of  the  posterior  pelvic  wall. 
It  is  shaped  like  a  pyramid  with  the  base  at  the  upper  part,  and  is  composed 
of  four  vertebras.  The  term  is  derived  from  sacer,  "sacred,"  because  it  helps 
protect  the  genitals,  which  were  held  to  be  sacred,  or  because  it  was  offered 
in  sacrifice.  The  coccyx — so  named  because  it  was  thought  to  look  like  the 
cuckoo's  beak — comprises  five  rudimentary  vertebrae.  It  is  shaped  like  a 
triangle  and  has  its  base  pointing  upward.  If  a  bony  union  is  established 
between  the  sacrum  and  coccyx,  it  may  offer  an  obstacle  to  labor;  normally 


Fig.  506. — Female  Bony  Pelvis. 


the  coccyx  remains  movable  until  middle  life.  It  represents  the  tail  appendage 
in  vertebrates. 

The  Pelvic  Joints. — By  their  existence  the  pelvis  is  possessed  of  a  certain 
amount  of  mobility  between  its  several  parts.  These  articulations  number 
seven — one  pubic,  two  sacro-iliac,  three  sacro-lumbar,  and  one  sacro-coccygeal. 
Five  of  these  articulations  are  amphiarthrodial,  much  like  those  between  the 
bodies  of  the  vertebra. 

Pubic  Joint  or  Symphysis  Pubis. — The  pubic  joint  or  "symphysis"  pos- 
sesses fibro-cartilages  similar  to  the  intervertebral  discs,  each  of  which  is  firmly 
attached  to  the  corresponding  pubic  bone.  This  cartilage  is  soft  in  the  center 
and  firmer  at  the  outside;  thicker  in  front  than  behind,  and  thicker  in  females 
than  in  males.  Many  assert  the  presence  of  a  synovial  membrane,*  though 
Morris,   Depaul,  and  French  authorities  generally   deny  its   existence  save  in 

*  Allen. 


THE  PELVIC  JOINTS. 


377 


exceptional  cases.  There  are,  besides,  four  ligaments — a  posterior,  a  superior, 
an  anterior,  and  an  inferior  sub-pubic  or  ligamentum  arcuatum.  By  the  last 
the  pubic  arch  is  filled  out  and  made  smooth  and  rounded  (Fig.  510).  In  the 
pregnant  woman  the  symphysis  together  with  the  other  joints  becomes  more 
movable.  The  softening  of  pregnancy  gives  rise  to  a  slight  gliding  movement. 
The  connected  surtaces  are  practically  not  separated,  as,  indeed,  this  separation 
would  have  to  be  considerable  to  increase  the  antero-posterior  diameters  to  any 
extent. 

Following  the  investigations  of  Budin,  I  have  made  examinations  of  several 
hundreds  of  pregnant  women  in  three  maternity  services,  over  a  period  of 
ten  years,  in  order  to  ascertain  if  there  were  movements  in  the  pubic  articu- 
lation.    The  ball  of  the  finger  was  placed  directly  against  the  lower  margin  of 


Fig.  507. — Male  Bony  Pelvis. 


the  symphysis  pubis,  and  then  the  woman  was  asked  to  walk  or  stand  first  on 
one  and  then  the  other  leg.  The  side  of  the  pubis  corresponding  to  the  free  leg 
was  found  to  descend,  while  the  bone  on  the  other  side  remained  fixed.  I  con- 
cluded that  there  is  invariably  present  in  this  joint  a  certain  amount  of  mobility 
which  increases  with  the  advance  of  pregnancy  and  with  the  number  of  preg- 
nancies, and  when  present  to  a  considerable  degree  the  subjects  have  no  difficulty 
in  walking;  the  mobility  is  very  slight  in  primigravidas.     (See  page  114.) 

Sacro-iliac  Joints. — The  sacro-iliac  articulation  joins  the  lateral  surfaces  of 
the  sacrum  and  ilium.  Some  anatomists,  among  whom  is  Luschka,  believe  that 
there  is  a  synovial  membrane,  especially  marked  in  pregnancy.  Morris  does  not 
hold  this  view;  at  least  he  does  not  believe  the  synovial  membrane  to  be  constant, 
although  it  is  more  apt  to  be  present  in  the  female  than  in  the  male.     There  are. 


378 


PHYSIOLOGICAL  LABOR. 


besides,  six  ligaments  to  make  the  joint  firm.  In  normal  labor  the  only  move- 
ment worthy  of  mention  in  these  joints  is  a  gliding  one,  and  by  it  the  antero- 
posterior diameter  of  the  pelvic  outlet  is  somewhat  increased.  In  five  sym- 
physeotomies I  obtained  from  two  to  two  and  a  half  inches  separation  at  the 
pubis,  and  subsequent  strong  fibrous  union  in  each  case  without  apparent  injury 
to  the  ligaments  of  the  sacro-iliac  joints.  This  proves  the  existence  of  a  certain 
amount  of  motion  at  these  joints,  and  also  of  considerable  stretching  of  the 
anterior  ligaments. 

I  believe  that  the  movements  taking  place  in  the  sacro-iliac  joints  during 
labor  are  important  to  its  progress.  There  is  an  elevation  and  depression  of 
the  pubis,  or  diminution  and  increase  of  pelvic  inclination;  or,  from  another 
point  of  view,  if  the  sacrum  is  considered  as  the  bone  that  moves,  it  oscillates 
in  an  imaginary  transverse  axis  which  passes  through  the  lower  part  of  the 
second  sacral  vertebra,  so  as  to  increase  the  pelvic  inlet  or  outlet.  j 


Fig.  508. — Posterior  View  of  Female  Bony  Pelvis. 


Sacro-vertehral  Articulation. — The  union  between  the  sacrum  and  the  last 
lower  lumbar  vertebra  is  like  that  between  the  other  vertebrae.  The  pecu- 
liarity of  this  joint  is  that  the  interarticular  disc  of  cartilage  is  just  twice  as 
thick  in  front  as  behind,  thus  forming  what  is  termed  the  "  sacro-vertebral 
angle"  (Fig.  511).  The  "pelvic  inclination,"  while  it  depends  in  a  great 
measure  upon  the  angle  thus  formed,  yet  is  produced  in  part  also  by  the 
obliquity  of  the  innominate  bones  to  the  sacrum.  The  union  between  the 
vertebral  bodies  is  amphiarthrodial,  while  that  between  the  apophyses  is 
arthrodial. 

Sacro-coccygeal  Joint. — The  most  movable  joint  is  the  sacro-coccygeal  joint, 
and  is  considered  a  part  of  the  pelvic  floor.  It  has  two  articular  surfaces,  an 
interosseous  fibro-cartilage,  and  four  peripheral  ligaments.  Firm  union  between 
the  coccyx  and  sacrum  occasionally  occurs  even  in  young  subjects,  but  is  most 
often  found  in  elderly  primiparas.     Generally,  however,  during  the  exit  of  the 


INTERNAL  SURFACE  OF   THE  PELVIS. 


379 


head  the  coccyx  is  pushed  back,  and  by  this  means  the  antero-posterior  diameter 
of  the  outlet  is  increased  to  the  extent  of  one  inch. 

Functions  of  the  Pelvic  Joints. — In  an  obstetric  sense  the  pelvic  joints  are 
designed  by  nature  not  so  much  to  increase  the  diameters  of  the  pelvis  by 


N 


Acetabulum. 
Ischial  Sp, 


Linea  ferifiinahs 
Supra-  spinous pkne 
Ischial  angle 
Infraspi'nal  plane 


Ischial  taierosi 


Fig.  509. — Transverse  Section  through  the  Acetabula  and  Ischial  Tuberosities, 
SHOWING  Posterior  Portion  of  the  Internal  Surfaces  of  the  False  and  True 
Pelvis. 


Superior  l^ament 


ParfofliTiea  alda 

Jtiffht  rectus  muscle 

Posterior  hgamcn  t 


the  swelling  they  undergo  in  pregnancy  and  by  the  slight  movements  occurring 
in  them  as  they  are  to  act  as  cushions  to  lessen  jars  and  shocks  that  might 
be  transmitted  to  the  spinal  cord,  uterus,  or  fetus,  from  blows,  falls,  and  trau- 
matisms in  general.  The  greatest  mobility  is  exerted  at  the  sacro-coccygeal 
joint,  less  at  the  pubic,  and 
least  at  the  sacro-iliac.  The 
sacrum  can  move  in  an 
antero-posterior  diameter, 
making  a  swing  of  i  cm.  for 
the  promontory.  This  is 
most  marked  when  the 
woman  is  on  her  back  with 
her  legs  hanging  over  the 
edge  of  the  table,  the  atti- 
tude known  as  "Walcher's 
hanging  position."  (See  Part 
X,  Posture  in  Obstetrics.) 

Internal  Surface  of  the 
Pelvis. — The  bony  pelvis 
may  be  regarded  as  a  cylin- 
der, contracted  near  its  mid- 
dle by  the  circumference  of 

the  pelvic  inlet,  which  divides  it  into  a  false  pelvis  above  and  a  true  pelvis  below. 
In  contrast  to  the  rough  and  irregular  external  surface,  the  internal  surface  of  the 
pelvis  is  smooth  and  symmetrical,  and  is  clearly  divided  into  the  two  parts  men- 
tioned above.     The  cavity  of  the  pelvis  may  be  considered  to  be  an  inverted, 


Fig.  510. — Anterior  Portion  of  the  Internal  Sur- 
face OF  the  Pelvis. 


380 


PHYSIOLOGICAL  LABOR. 


truncated  cone.  The  dividing-line  consists  of  the  ilio-pectineal  line,  supple- 
mented by  the  superior  anterior  margin  of  the  sacrum  and  its  alae,  or  the 
boundar>^-line  is  the  circumference  of  the  pelvic  inlet  (Fig.  509). 

The  False  Pelvis. — The  false,  superior,  or  large  pelvis  is  bounded  behind 
by  the  last  lumbar  vertebra  and  the  ilio-lumbar  ligaments;  on  the  sides  by 
the  iliac  bones;  in  front  there  is  a  gap  filled  up  in  the  recent  state  by  the  elastic 
lower  abdominal  wall.  If  the  convergence  of  the  bony  walls  of  the  false  pelvis 
were  continued  downward,  they  would  meet  at  a  point  corresponding  with 
the  fourth  sacral  vertebra.  It  is  from  this  fact  that  the  false  pelvis  has  often 
been  compared  to  a  funnel.  The  false  pelvis  really  belongs  to  the  abdominal 
cavity,  and  to  its  contents  it  offers  protection  and  support;  it  has  no  marked  ob- 
stetric value.  In  multigravidous  women  the  iliac  fossa  serves  to  support  the 
fetal  head.     It  forms  an  inclined  plane  which  serves  as  a  guide  to  the  fetus  and 


Fig.  511. — Sagittal  Section  through  the  Middle  of  the  Sacrum  and  Pubic  Joint 
SHOWING  the  Internal  Lateral  Surfaces  of  the  False  and  True  Pelvis. — 
(From  the  author's  aluminium-  cast  of  a  female  pelvis.) 


directs  it  downward  when  impelled  by  contractions  of  the  uterus,  and  thus  aids 
its  engagement  in  the  pelvic  inlet ;  and  not  unless  it  be  very  much  deformed  will 
it  obstruct  the  passage  of  the  child. 

False  Pelvis  and  External  Measurements. — (See  Pelvimetry,  page  163.) 
The  True  Pelvis. — The  true,  inferior,  or  small  pelvis  is  that  part  below  the 
ilio-pectineal  line,  and  it  forms  the  true  obstetric  pelvis  (Fig.  509).  The  true 
pelvis  in  the  female  is  much  larger  than  that  in  the  male.  It  is  bounded  poste- 
riorly by  the  concavity  of  the  sacrum ;  on  the  sides  by  the  sacro-sciatic  liga- 
ments and  the  internal  surfaces  of  the  acetabula  and  obturator  membranes  ; 
anteriorly,  by  the  pubic  bones  and  obturator  membranes.  If  any  horizontal 
plane  of  this  curved  cylinder — the  true  pelvis — is  taken  at  a  level,  the  bony 
wall  is  incomplete.  In  any  plane  that  may  be  selected  there  will  be  a  foramen 
covered  by  membrane  or  by  distensible  and  elastic  muscular  or  fibrous  tissue ; 


PELVIC  INLET. 


381 


or  a  movable  joint  such  as  the  coccyx  directly  opposite  the  solid  mass  of  the 
pubic  bones ;  or  some  elastic  tissue  that  will  permit  of  considerable  compression 
without  injury.  The  conclusion  to  be  drawn  from  this  fact  is  that  although 
the  fetus  must  pass  through  this  bony  cylinder  to  reach  the  external  world, 
yet  by  the  peculiar  formation  of  the  pelvis  both  the  fetus  and  the  mother's 
soft  parts  are  protected  against  too  great  or  too  prolonged  pressure;  while  if  con- 
cussions should  occur,  their  effect  would  be 
much  alleviated. 

The  Pelvic  Inlet. — The  pelvic  inlet,  supe- 
rior strait,  brim,  margin,  isthmus,  linea  ter- 
minale,  linea  ilio-pectinea,  is  the  entrance  to 
the  cavity  of  the  true  pelvis.  The  superior 
strait  and  the  inferior  strait  received  their 
names  because  they  were  thought  to  be  more 
contracted  than  the  space  which  lies  between 
them.  I  prefer  the  term  pelvic  inlet.  The 
anatomical  inlet  is  the  entrance  of  the  small 
or  true  pelvis,  and  corresponds  to  the  upper 
margin  of  the  symphysis  pubis,  and  to  the 
edges  of  the  bones  extending  backward  to 
the  sacral  promontory  (Fig.  513).  The  ob- 
stetric inlet  is  the  least  available  space  at 
the  upper  portion  of  the  pelvic  canal;  it  is 
bounded  by  a  line  passing  f  inch  (i  cm.)  be- 
low the  upper  margin  of  the  symphysis  pubis, 
along  the  posterior  margin  of  the  oblique 
rami  and  body  of  the  pubis,  past  the  ilio- 
pectineal  eminences,  the  anterior  margin  of 
the  sacral  alas,  and  the  summit  of  the  sacral 
promontory. 

Shape. — The  shape  of  the  inlet  in  the 
bony  pelvis  is  that  of  a  curvilinear  triangle 
with  the  base  behind  and  the  apex  in  front, 
the  chief  irregularity  being  found  in  the  sac- 
ral promontory.  It  is  here  that  pelvic  de- 
formities cause  by  far  the  greatest  trouble, 
and  hence  an  intimate  knowledge  of  the  pel- 
vic inlet  is  necessary  (Fig.  513). 

Pelvic  Inlet  Measurements. — (See  Pelvi- 
metry, page  167.)  The  circumference  of  the 
pelvic  inlet  is  16  inches  (40.5  cm.). 

Obstetric  Landmarks  of  the  Inlet. — (i)  The 
symphysis  pubis  in  front;  (2)  just  posterior 
on  either  side,  situated  upon  the  pubic  bone, 

close  to  the  iho-pubic  junction,  is  found  a  rough  eminence — the  ilio-pectineal 
eminence;  (3)  the  boundary-line  of  the  inlet  on  either  side,  known  as  the  linea 
terminalis;  or  more  commonly,  from  its  source  of  origin,  as  the  ilio-pectineal 
line;  (4)  the  points  on  the  sacro-iHac  joints  at  which  the  linea  pectinea  joins 
them;  (5)  the  promontory  of  the  sacrum  or  the  sacro-vertebral  angle.  The 
intervertebral  cartilage  between  the  sacrum  and  last  lumbar,  being  wedge-shaped 
and  thicker  in  front,  forms  an  angle  between  the  sacrum  and  vertebral  column 
and  causes  the  inclination  of  the  pelvis. 


Fig.  512. — Vertical  Mesial  Section 
OF  "a  Female  Pelvis  showing  the 

LUMBO-SACRO-COCCYGEAL         CuRVE, 

THE  Inclination  and  Shape  of  the 
Symphysis,  the  Relations  of  the 
Anatomical,  Obstetric,  and  Diag- 
onal Diameters  of  the  Pelvic  In- 
let, and  the  Sacro-pubic  and  Coc- 
cygo-pubic  Diameters  of  the  Pel- 
vic Outlet.  The  Lower  Figure 
shows  the  Pubic  Arch. — (Front  the 
author's  lead-tape  tracings.) 


382 


PHYSIOLOGICAL  LABOR. 


The  Pelvic  Cavity. — The  pelvic  cavity,  pelvic  canal,  excavation,  small  or 
true  pelvis,  is  the  portion  bounded  by  the  inlet  above,  the  outlet  below,  in 
front  by  the  symphysis  pubis,  at  the  sides  by  the  innominate  bones,  and  behind 
by  the  hollow  of  the  sacrum  and  the  coccyx.  The  pelvic  cavity  is  irregularly 
barrel-shaped  or  cylindrical.  It  must  never  be  forgotten  that  the  pelvis  offers 
a  curved  and  not  a  straight  cylinder  to  deal  with — a  cylinder  bent  upon  itself, 
so  to  speak.  If  this  fact  be  overlooked,  the  most  important  factor  in  deter- 
mining the  mechanism  of  delivery  is  ignored.  This  cavity  may  be  conveniently 
separated  into  four  regions:  anterior,  posterior,  and  two  lateral  (Figs.  509 
to  511).  The  anterior  region  has  a  marked  notch  in  the  pubic  arch.  The 
surface  is  convex  from  above  downward,  and  concave  from  side  to  side.  In 
the  middle  of  this  region  the  posterior  part  of  the  articulation  of  the  symphysis 


Fig.  513. — The  Superior  Surface  of  the  Pelvis  showing  the  Shape  and  Diameters 

OF  THE  Pelvic  Inlet. 


pubis  projects  vertically  and  makes  a  prominence  of  from  i  to  |  of  an  inch 
(0.63  to  I  cm.).  Toward  the  sides  the  surface  is  smooth,  and  then  come  the 
internal  obturator  or  sub-pubic  fossas.  The  posterior  region  consists  of  the 
surfaces  of  the  sacrum  and  coccyx.  This  part  is  concave  from  above  down- 
ward, the  curve  being  deepest  at  the  junction  of  the  second  and  third  sacral 
vertebrae.  Down  to  this  point  the  curve  is  very  fiat;  which  makes  the  axis 
of  the  cavity  straight  above  this  level.  The  lateral  regions  consist  of  two 
well-defined  parts;  the  anterior  being  entirely  bony  and  corresponding  to  the 
posterior  part  of  the  acetabula  and  to  the  ischial  body  and  tuberosity;  and 
its  direction  is  from  above  downward,  from  without  inward,  and  from  behind 
forward.  The  posterior  part  consists  for  the  most  part  of  the  internal 
face  of  the  sacro-sciatic  ligaments  and  foramina.     The  direction  of  this  part  is 


PELVIC  OUTLET. 


383 


the  converse  of  the  anterior,  it  being  from  above  downward,  from  without 
inward,  and  from  before  backward. 

Pelvic  Cavity  Measurements. — (See  Pelvimetry,  page  167.) 

The  depth  of  the  pelvis  at  the  symphysis  is  if  inches  (4  cm.).  The  depth  of 
the  lateral  wall  over  the  smooth  surface  of  the  ischial  bones  is  32  inches  (9  cm.). 
The  depth  of  the  posterior  wall,  following  the  course  of  the  sacrum  and  coccyx 
from  promontory  to  tip  of  coccyx,  is  4^  to  5  inches  (11. 5  to  12.5  cm.). 

The  obstetric  landmarks  of  the  cavity  are  as  follows:  (i)  The  pubic  joint 
in  front;  (2)  the  obturator  foramen;  (3)  the  spine  of  the  ischium;  (4)  the 
great  sacro-sciatic  ligament  and  foramen;  (5)  the  small  sacro-sciatic  ligament 
and  foramen;  (6)  the  sacrum  and  coccyx. 

The  Pelvic  Outlet. — The  pelvic  outlet  or  inferior  strait  is  the  lower  opening 
of  the  cavity  of  the  true  pelvis  (Fig.  515).     While  there  is  at  the  pelvic  inlet 


Fig.  514. — Transverse  Section  through  the  True  Pelvis  Just  below  the  Pelvic 
Inlet  and  Parallel  to  it. — {Author's  collection.) 


a  continuous  ring  of  bone,  the  circumference  of  the  pelvic  outlet  is  partly  bony 
and  partly  ligamentous,  and  there  are,  besides,  certain  projections  not  found 
at  the  inlet;  namely,  the  spines  and  tuberosities  of  the  ischia  separated  by 
notches,  and  certain  indentations  also,  the  most  important  being  the  pubic 
arch.  The  anatomical  outlet  is  the  real  outlet  of  the  true  pelvis  and  is  bounded 
behind  by  the  coccyx;  in  front  by  the  sub-pubic  ligament;  on  the  sides  by 
the  ischio-pubic  rami,  the  ischial  tuberosities,  and  the  greater  and  lesser  sciatic 
ligaments.  The  obstetric  outlet  is  just  above  this,  and  is  the  circumference 
of  greatest  bony  resistance  of  the  true  pelvis  as  well  as  the  smallest  in  size. 
It  is  bounded  by  the  posterior  surface  of  the  symphysis  pubis  about  \  inch 
(0.625  cm.)  above  the  lower  margin;  the  upper  portions  of  the  ischial  tuber- 
osities and  the  lower  border  of  the  sacrum. 

Shape. — Its  shape  is  that  of  a  diamond  or  of  two  triangles  having  a  common 


384 


PHYSIOLOGICAL  LABOR. 


base,  and  varies  with  the  mobility  of  the  coccyx,  and  in  labor  it  becomes  almost 
circular,  thus  being  more  changeable  than  the  pelvic  inlet.  In  the  sitting 
posture  the  weight  of  the  body  rests  entirely  on  the  ischial  tuberosities,  since 
they  are  on  a  lower  plane  than  the  tip  of  the  coccyx;  and  this  explains  why 
transverse  pelvic  contractions  are  so  much  more  frequent  at  this  strait  than 
are  the  antero-posterior  ones.  Although  the  two  lateral  notches  are  so  deeply 
marked  in  the  bony  pelvis,  they  are  made  very  superficial  by  the  sacro-sciatic 
ligaments  The  anterior  notch  is  known  as  the  arch  of  the  pubis.  The  col- 
umns of  this  arch  are  twisted  outward, — this  being  more  marked  in  the  female, — 
and  so  assist  in  the  passage  of  the  head  in  labor.  By  the  yielding  of  the  sciatic 
ligaments   the  oblique    diameters    may    be    somewhat   increased;    this    is   not 


cjSWiPHy^/^ 


Fig.  515. — The  Inferior  Surface  of  the  Pelvis,  showing  the  Shape  and  Diameters 

OF  THE  Pelvic  Outlet. 


important.  However,  there  is  an  important  increase  in  the  antero-posterior 
diameter,  resulting  from  recession  of  the  coccyx,  so  that  although  this 
diameter  is  the  shortest  one  of  the  irilet,  it  becomes  the  longest  of  the  outlet. 

Pelvic  Outlet  Measurements. — (See  Pelvimetry,  page  168.)  The  circumference 
of  the  pelvic  outlet  is  18  inches  (45  cm.). 

Obstetric  Landmarks  of  the  Outlet. — Taking  them  from  before  backward, 
we  have:  (i)  The  pubic  arch,  and  at  its  apex  the  sub-pubic  ligament.  (2) 
Passing  backward,  we  have  the  descending  ramus  of  the  pubis  and  ascending 
ramus  of  the  ischium  which  assist  in  bounding  the  obturator  foramen  and  in 
forming  the  pubic  arch.  (3)  At  the  junction  of  the  two  ischial  rami  is  a  thick- 
ened projection,  the  tuberosity  of  the  ischium.  (4)  Upon  the  posterior  border 
of  the  descending  ischial  ramus,  and  projecting  forward,  is  a  sharp  spine, — 
the  spine  of  the  ischium, — which  when  well  marked  plays  an  important  part 


PELVIC  PLANES 


385 


in  the  mechanism  of  labor.     (5)  The  great  and  small  sacro-sciatic  ligaments. 
(6)  The  coccyx. 

Pelvic  Planes. — The  planes  of  the  pelvis  are  imaginary  levels  at  different 
portions  of  the  cavity;  thus,  we  have  a  plane  of  the  inlet,  planes  of  the  cavity, 
and  a  plane  of  the  outlet.  By  a  pelvic  plane  we  mean  simply  a  mathematical 
surface  without  depth  or  thickness.  The  short,  slightly  curved,  cylindrical 
cavity  of  the  true  pelvis,  bounded  by  the  bony  walls  already  described, 
varies  in  shape  and  size  at  various  levels.  For  convenience  in  describing 
these  variations  and  pelvic  inclination  and  angles,  we  erect  imaginary  levels 
at  different  parts  of  the  cavity  of  the  true  pelvis.  If  we  accurately  fit  a  piece 
of  cardboard  into  the  inlet  of  the  pelvis,  the  level  surface  thus  produced  would 


Fig.  516. — Planes  of  the  Bony  Pelvis  and  Parturient  Tract.  Plane  of  the  parturient 
inlet;  plane  of  the  bony  inlet;  pubo-sacral  plane  of  the  outlet;  pubo-coccygeal  plane 
of  the  outlet;  plane  of  the  parturient  outlet 


represent  the  plane  of  the  pelvic  inlet  (Fig.  516).  In  like  manner  we  have  a 
plane  of  the  outlet,  and  planes  of  the  cavity.  It  is  in  studying  these  pelvic 
planes  that  we  observe  that  the  planes  of  the  inlet  and  outlet  are  not  parallel 
with  each  other,  are  not  at  right  angles  with  the  axis  of  the  body,  nor  are  they 
parallel  with  the  horizon.  (See  Pelvic  Angles.)  Moreover,  it  is  upon  changes 
in  the  shape  and  size  of  these  pelvic  planes  that  the  presence  of  pelvic  deformity 
depends. 

Plane  of  the  Pelvic  Inlet  (Fig.  516). — As  the  obstetric  conjugate  is  the  avail- 
able antero-posterior  space  at  the  inlet,  so  the  obstetric  plane  of  the  inlet  is 
the  space  available  at  the  inlet  for  the  passage  of  the  fetal  head  and  body. 
It  does  not  coincide  with  the  anatomical  conjugate  nor  with  the  anatomical 
25 


386 


PHYSIOLOGICAL  LABOR. 


inlet.  The  plane  of  the  obstetric  inlet  would  be  represented  by  a  piece  of 
cardboard  that  so  fitted  the  entrance  of  the  pelvis  that  its  margins  corre- 
sponded to  the  base  of  the  sacrum,  the  ilio-pectineal  line,  and  the  posterior 
surface  of  the  symphysis  along  a  transverse  line  f  inch  (i  cm.)  below  its  upper 
margin. 

Planes  of  the  Pelvic  Cavity  (Fig.  516). — Hodge  constructed  a  series  of  planes 
parallel  to  the  plane  of  the  inlet.  These  planes  are  obsolete,  and  we  now  speak 
of  the  plane  of  greatest  pelvic  dimensions  or  middle  plane.*  It  extends  from 
the  middle  of  the  posterior  surface  of  the  symphysis  pubis,  over  the  central 
points  of  the  internal  surfaces  of  the  acetabular  cavities,  to  the  upper  margin 


Fig.  517. — Planes  of  the  Bony  Pelvis  and  Parturient  Tract,  and  Axes  of  the  Par- 
turient Inlet  and  of  the  Bony  and  Parturient  Outlets. 


of  the  third  piece  of  the  sacrum.     This  is  the  largest  plane  of  the  pelvis;  the 
next  in  size  is  that  of  the  inlet,  and  that  of  the  outlet  is  the  smallest. 

Plane  of  the  Pelvic  Outlet  (Fig.  516). — As  at  the  inlet,  so  here  we  have  an 
anatomical  plane  of  the  outlet  and  an  obstetric  plane.  The  latter  is  somewhat 
above  the  former  and  is  the  plane  of  greatest  bony  resistance  at  the  outlet. 
It  is  also  the  smallest  transverse  plane  of  the  entire  pelvis,  and  we  also  term 
it  the  plane  of  least  pelvic  dimensions.! 

*  German,  Beckenweite. 

t  Beckenenge.  It  touches  the  posterior  surface  of  the  symphysis  pubis  about  -J  of  an 
inch  above  its  lower  margin,  just  above  the  ischial  tuberosities,  and  the  lower  border  of 
the  sacrum.  While  this  is  the  smallest  transverse  plane  of  the  pelvis,  it  must  be  remem- 
bered that  the  yielding  character  of  the  sciatic  ligaments  allows  of  marked  expansion  in 
the  posterior  segment  during  the  expulsion  of  the  fetus. 


PELVIC  INCLINATION  AND  PELVIC  ANGLES.  387 

Plane  of  the  Parturient  Outlet  (Figs.  516  and  517). — At  the  moment  that 
the  presenting  part  is  expelled,  the  plane  of  the  parturient  outlet,  or,  to  be 
more  exact,  of  the  vulvo-vaginal  ring,  is  nearly  parallel  with  the  long  axis  of 
the  mother's  body,  and,  with  the  woman  in  the  dorsal  posture,  looks  almost 
directly  upward. 

Pelvic  Axes. — The  axes  of  the  pelvis  are  imaginary  lines  passing  through 
the  centers  of  the  planes  of  the  pelvis,  and  at  right  angles  to  them  (Fig.  517). 
The  axis  of  the  inlet  is  represented  by  a  line  drawn  perpendicular  to  the  center 
of  the  plane  of  the  pelvic  inlet.  This  line,  prolonged  upward,  strikes  the  anterior 
abdominal  wall  near  the  umbilicus;  and  projected  downward,  ends  at  the 
fourth  piece  of  the  sacrum  (Fig.  517).  The  axis  of  the  cavity  is  represented 
by  a  curved  line  joining  the  centers  of  a  series  of  planes  extending  from  the 
pelvic  inlet  to  the  outlet,  and  including  these  latter  planes.  It  should  be  stated 
that  the  axis  of  the  true  pelvis  is  an  axis  of  a  curved  and  not  a  straight  cylinder, 
and  hence  is  a  curved  line,  and  practically  is  dependent  upon  the  curves  of 
the  sacrum  and  coccyx,  and  thus  of  necessity  differs  according  to  the  indi- 
vidual. The  axis  of  the  parturient  tract,  as  will  be  shown  later  (Fig.  517),  is 
a  continuation  of  the  axis  of  the  cavity  beyond  the  bony  outlet,  by  the  dis- 
tention of  the  tissues  which  go  to  form  the  pelvic  floor.  (See  page  408.)  The 
axis  of  the  bony  outlet  is  a  perpendicular  line  passing  through  the  center  of  the 
plane  of  the  outlet,  and  when  there  is  no  recession  of  the  coccyx,  this  line, 
prolonged  upward,  strikes  the  promontory;  when  the  coccyx  is  pushed  back- 
ward, the  axis  of  the  outlet  strikes  the  lower  border  of  the  first  sacral  vertebra. 
The  axis  of  the  parturient  outlet  is  a  perpendicular  line  passing  through  the 
center  of  the  plane  of  the  parturient  outlet.  This  line  is  nearly  at  right  angles 
with  the  long  axis  of  the  mother's  body,  and  is  nearly  perpendicular.  If  extended 
backward  and  downward,  it  passes  some  distance  below  and  in  front  of  the 
end  of  the  coccyx. 

Pelvic  Inclination  and  Angles. — In  the  upright  posture  of  the  body  the 
plane  of  the  pelvic  inlet  is  inclined  obliquely  downward.  The  angle  between 
the  conjugate  and  horizon  measures  55  to  60  degrees,  while  the  same 
angle  at  the  outlet  is  11  degrees  (Fig.  517).  The  inclination  exhibits  a  good 
deal  of  variability.  Not  only  are  there  differences  in  the  same  measurement 
in  different  individuals,  but  the  angle  is  essentially  altered  by  the  position 
of  the  limbs.  Thus,  it  is  increased  by  extreme  flexion  of  the  legs  and  by  extreme 
abduction  and  outward  rotation  of  the  thighs.  The  angle  is  smaller  when 
the  thighs  are  moderately  abducted  and  in  slight  inward  rotation.  The  size 
of  the  angle  of  inclination  may  be  of  diagnostic  importance,  since  it  calls  our 
attention  to  certain  anomalies  of  the  pelvis.  As  a  rule,  a  change  in  the  direction 
of  the  plane  of  the  inlet  means  a  corresponding  alteration  in  the  axes  of  the 
uterus  and  fetus,  so  that  the  influence  of  the  inclination  up  on  labor  is  much  less 
than  was  formerly  supposed.  On  the  other  hand,  the  variation  of  the  plane 
of  the  inlet  and  axis  of  the  uterus  in  the  different  postures  of  the  body  is  a 
matter  of  importance  to  the  obstetrician,  (i)  If  the  woman  lie  flat  on  her 
back  with  extended  limbs,  the  plane  of  the  inlet  sinks  backward  until  it  forms 
an  angle  of  25  degrees,  open  in  front,  with  the  horizon.  (2)  If  she  assume 
the  knee-chest  position,  this  plane  forms  with  the  horizon  an  angle  of  15  or 
20  degrees,  open  behind.  (3)  If  the  pelvis  and  spinal  column  are  approximated, 
the  size  of  the  angle  is  increased.  (4)  If  the  woman  lie  upon  her  back  across 
the  bed  in  such  manner  that  her  thighs  hang  over  the  side  of  the  latter,  the 
pelvic  inlet  is  expanded.  This  is  the  so-called  Walcher  position,  to  be  con- 
sidered from  another  point   of  view.     (See   Posture  in   Obstetrics,   Part   X.) 


388 


PHYSIOLOGICAL  LABOR. 


Fig.  518. — Early  Antenatal 
Pelves.  (Natural  size.)  — 
{Author's  collection.) 


In  this  connection  it  is  only  necessary  to  state  that 
while  the  angle  between  the  inlet  plane  and  horizon 
is  less  than  in  the  fiat  dorsal  position,  the  angle  be- 
tween the  conjugate  and  lumbar  spine  is  notably 
increased.  (5)  If  the  woman,  lying  upon  her  back, 
flexes  her  legs  at  both  the  hip  and  knee,  and  at  the 
same  time  approximates  them  moderately,  form- 
ing the  lithotomy  position,  the  pelvis  rotates  a 
little  upon  its  transverse  axis  so  that  the  angle  of 
the  fiat  dorsal  position  is  increased  from  25  to  30 
degrees  or  over.  (See  Part  X.)  If  now  the  thighs 
and  legs  are  flexed  to  the  utmost  so  that  the  thighs 
are  pressed  tightly  against  the  abdomen, — the 
exaggerated  lithotomy  position, — the  pelvis  con- 
tinues to  rotate  upon  its  transverse  axis  until  the 
angle  reaches  60  degrees.  There  is  a  corresponding 
diminution  in  the  angle  between  the  spine  and 
conjugate.  (See  Part  X.)  (7)  If  with  the  woman 
in  the  fiat  dorsal  position  the  trunk  is  raised  so 
that  a  reclining  posture  is  assumed,  the  original 
angle  of  25  degrees  is  reduced  to  20  degrees.  In 
the  squatting  or  crouching  posture  the  plane  of 
the  inlet  is  almost  horizontal,  and  hence  hardly 
any  angle  is  present.  Variations  in  the  angle  be- 
tween the  spine  and  pelvis  are  made  possible  by 
the  slight  mobility  of  the  sacro-iliac  joints  and  of 
the  vertebras  with  each  other  and  with  the  sacrum. 
As  has  already  been  stated,  the  Walcher  position 
causes  an  expansion  of  the  pelvic  inlet.  The  oppo- 
site eflect  of  contraction  is  produced  by  the  exag- 
gerated lithotomy  posture.  For  a  statement  of 
these  phenomena  and  their  practical  application 
to  the  mechanism  of  delivery  see  Posture  in  Ob- 
stetrics, Part  X.  If  a  perpendicular  falls  at  the 
middle  of  the  pelvic  inlet,  it  should  pass  through 
the  coccyx  below  and  the  umbilicus  above,  pro- 
vided that  the  angle  between  the  vertebral  column 
and  conjugate  is  normal  (125  degrees).  If  the  per- 
pendicular passes  through  the  center  of  the  outlet, 
it  would  pass  through  the  promontory  above.  The 
symphysis  makes  an  angle  with  the  inlet  of  from 
90  to  100  degrees.  See  also  section  on  Cliseometry, 
page  178. 

Comparison  of  Different  Pelvic  Diameters. — 
The  most  important  facts  to  be  remembered  here 
are  the  diameters  of  inlet  and  outlet.  As  has  been 
already  noted,  the  shortest  diameter  of  the  inlet 
(antero-posterior,  4^  in. — 11.25  cm.)  corresponds 
when  the  coccyx  has  receded  with  the  longest 
diameter  of  the  outlet;  and,  conversely,  with  the 
longest  diameter  at  the  inlet  (transverse,  51-  in. — 
13.12  cm.)  to  the  shortest  at  the  outlet  (4!  in. — 


FACTORS  INFLUENCING  DEVELOPMENT  OF  THE  PELVIS.     389 

II  cm.).  In  considering  the  mechanism  of  labor  and  the  slow  progress  of  the 
head  as  it  gradually  descends  through  the  pelvic  canal,  a  general  rule  will  be  ob- 
served concerning  the  relationship  existing  between  the  fetal  head  and  these 
several  diameters  of  the  bony  pelvis — namely,  the  long  diameter  of  the  fetal 
head  corresponds  to  the  longest  diameter  of  the  true  pelvis. 

Factors  Influencing  Size  and  Shape  of  the  Pelvis. — i.  Individuality. — The  pel- 
vis presents  great  individual  variations.  No  two  pelves  are  exactly  alike.  This 
is  due  to  the  varying  influences  of  infancy  and  childhood,  and  shows  itself  in  the 
thickness  and  shape  of  the  bones,  and  the  resulting  influence  upon  the  cavity  of 
the  true  pelvis  and  the  measurements  in  general.  So  great  is  the  variation  in  the 
flaring  of  the  ilia  that  we  are  accustomed  to  ignore  the  measurements  between 
these  bones  in  external  pelvimetry. 

2.  Sex. — Just  as  in  the  other  bones  of  the  body,  those  of  the  pelvis  are 
stronger,  thicker,  and  rougher  in  the  male  than  they  are  in  the  female  (Fig. 
507).  The  chief  differences  concern  the  cavity,  and  these  are  dependent  in 
the  female  on  the  presence  of  the  uterus.  The  male  pelvis  is  far  more  angular 
and  markedly  cordate  than  the  female,  its  structure  is  heavier,  and  it  is  less 
delicately  curved.  The  female  pelvis  is  broader  and  its  cavity  is  rounder 
(Fig.  506).  The  dimensions  of  the  internal  iliac  fossa  are  less  in  the  female 
except  the  line  drawn  between  the  anterior  superior  iliac  spine  and  the  sacro- 
iliac joint;  the  iliac  fossa  is  shallower  in  the  female;  the  pelvis  of  the  male 
is,  as  compared  with  that  of  the  female,  small,  deep,  steep,  and  funnel-shaped; 
the  tuberosities  of  the  ilium  are,  in  the  male,  more  developed  and  extend 
farther  back;  the  pubic  spines  as  well  as  the  ischial  tuberosities  are  more 
widely  separated  in  the  female.  The  sacrum  presents  two  curves,  concave 
from  above  downward  and  from  side  to  side;  this  is  more  marked  in  the  female 
than  in  the  male,  the  bone  being  shorter  and  its  direction  downward  and  back- 
ward; in  rachitis  the  lateral  concavity  becomes  straight  or  even  convex;  the 
vertical  concavity  is  not  an  arc  of  a  circle  but  is  bent;  this  bending  point  is 
known  as  the  niche,  and  is  found  in  the  third  sacral  vertebra.  The  inlet  is 
rounder  in  the  female,  and  all  the  dimensions  are  greater,  especially  the  trans- 
verse, which  is  not  only  longer  but  is  placed  farther  forward  than  in  the  male 
pelvis.  The  outlet  in  the  female  is  much  larger  on  account  of  the  recession 
of  the  ends  of  the  sacrum  and  coccyx  and  the  greater  distance  between  the 
tuberosities.  The  acetabula  are  relatively  farther  apart  and  their  surfaces 
look  forward  rather  obliquely;  this  arrangement  is  not  made  to  assist  the 
function  of  the  hip-joints  in  walking,  and  it  accounts  for  the  proximity  of  the 
knees  of  the  female  and  for  the  peculiarity  of  gait.  The  sciatic  notch  is  shal- 
lower and  more  open  in  the  female.  The  pubic  arch  in  the  male  is  more  acute, 
or  about  70  to  80  degrees;  in  the  female  it  is  more  rounded,  80  to  105  degrees; 
the  distance  between  the  symphysis  and  the  tuberosities,  the  anterior  pelvic 
wall,  is  longer  than  that  of  the  female;  in  the  female  the  ischio-pubic  tubercle 
is  turned  more  outward  and  the  ischio-pubic  ramus  is  concave  in  the  middle. 
In  the  female  there  is  marked  pelvic  inclination,  while  in  the  male  it  is  slight. 
In  the  male  the  sacrum  and  coccyx  are  higher  and  more  curved  than  in  the 
female.  The  ischio-pubic  foramen  in  the  female  is  relatively  larger  and  is  more 
oblique  externally  and  inferiorly ;  the  common  error  that  there  is  a  difference  in 
its  shape  in  man  and  woman  has  been  disproved.  The  ischia  are  more  widely 
separated  in  the  female;  all  the  vertical  diameters  of  the  pelvis  are  greater 
in  the  male.  Just  as  in  other  bones  of  the  body,  these  characteristic  differences 
in  some  pelves  are  marked,  while  in  others  they  are  slight,  so  as  to  make  the 
distinction  between  male  and  female  pelves  difficult. 


390  PHYSIOLOGICAL  LABOR. 

3.  Age. — Infantile  and  juvenile  pelvis.  The  pelvis  is  very  small  in  the 
newly  bom  child  and  is  far  less  developed  than  the  upper  part  of  the  body,  and 
to  this  cause  is  due  the  greater  prominence  of  the  abdomen  (Figs.  518  to  523). 
The  larger  part  of  the  rectum  and  the  bladder  are  almost  wholly  in  the  abdominal 
cavity,  and  it  is  not  till  puberty  that  their  permanent  position  is  assumed. 
Delivery  is  naturally  made  easier  from  the  small  size  of  the  pelvis.  At  the  time 
of  birth  there  is  a  greater  development  of  the  false  than  of  the  true  pelvis,  the 
latter  being  straight  and  cylindrical  in  shape.  It  was  not  till  recently  that  the 
infantile  pelvis  has  been  supposed  to  possess  any  special  form.  It  is  in  great 
measure  cartilaginous  with  points  of  ossification.  The  characteristics  of  the  in- 
fantile pelvis,  as  compared  with  the  adult,  are:  (i)  The  os  innominatum  is  com- 
posed of  ilium,  ischium,  and  pubis ;  the  ascending  and  descending  rami  are  entirely 
cartilaginous;  (2)  the  infant's  pelvis  is  relatively  more  contracted;  (3)  the  iliac 
bones  stand  more  perpendicularly;  (4)  the  sub-pubic  angle  is  less;  (5)  the  pro- 
montory of  the  sacrum  is  much  higher  and  the  sacrum  is  almost  entirely  straight ; 
(6)  the  promontory  of  the  sacrum  forms  a  much  more  obtuse  angle  with  the  spinal 


f^^^ 


^"\\ 


Fig.  519. — Antenatal   Pelvis  of  about  Fig.   520. — Antenatal  Pelvis  of  about 

THE  Seventh  Month.     (Natural  size.) the  Eighth  Month.     (Natural  size.)  — 

{Author's  collection.)  {Author's  collection.) 

column  than  is  found  in  the  adult  pelvis  (Figs.  518  to  521).  The  sacrum  has 
twenty-one  centers  of  ossification;  each  vertebral  body,  five;  each  vertebral  arch, 
ten ;  and  three  on  each  side  of  the  sacrum,  making  six  for  the  alas.  This  condi- 
tion persists  for  some  time,  and  it  is  not  till  late  that  the  centers  join.  According 
to  Litzmann,  they  unite  from  below  upward;  at  three  years  the  three  lower  bones 
are  ossified;  at  seven  years  the  sacrum  is  ossified;  the  three  bones  of  the  os  in- 
nominatum join  at  puberty;  at  twenty,  the  pelvis  assumes  its  normal  shape. 
The  sacrum  in  the  newly  born  child  is  more  or  less  wedge-shaped,  but  does  not 
possess  the  antero-posterior  curve  of  the  adult  sacrum  and  has  little  or  no  curve 
from  side  to  side;  the  diminution  is  due  to  pressure  causing  the  bodies  of  the 
vertebrae  to  press  forward  (Fig.  521).  The  alae  are  poorly  developed;  the  pro- 
montory of  the  sacrum  is  farther  above  the  symphysis  pubis ;  this  distance  is  so 
great  that  Fehling,  in  considering  the  genesis  of  the  pelvis,  does  not  use  the  con- 
jugata  vera,  but  what  he  terms  the  conjugata  vera  inferior.  The  transverse  width 
is  less  in  the  infant  and  the  shape  is  more  like  a  funnel,  the  pelvic  walls  being 
more  markedly  inclined. 

Forces  Leading  to  the  Production  of  the  Adult  Pelvis. — These  are  important 


FACTORS  INFLUENCING  DEVELOPMENT  OF  THE  PELVIS.      391 


'd 


'\ 


'^, 


/ 


,^ 


Fig. 


521. — Fetal   Pelvis   at   the   Fortieth    Week. 
(Natural  size.) — (Author's  collection.) 


because  they  somet'imes  lead  to  deformed  pelves.     There  are  two  sets  of  factors 
to  be  considered,     (i )   Congenital  predisposition  or  tendency  oj  the  pelvis  to  assume 
a  certain  form.     This  is  evident  when  the  differences  between  male  and  female 
pelves  are  noted,  as  both  are  subjected  to  the  same  forces.     At  birth  the  alae  of 
the  first  sacral  vertebra  are 
only  one-half  as  long  as  the 
vertebral  body  itself.     In  the 
adult  woman  the  alae  are  0.76 
as  long  as  the  body.     In  the 
adult  man  they  are  0.56  as 
long,  making  a  difference  of 
twenty  per  cent.  The  body  of 
the  second   vertebra  is  three 
times  as  broad  as  in  the  child; 
the  alse  are  five  times  longer  in 
woman    and   three   times    in 
man.      (2)  Mechanical   influ- 
ences.   These  are  very  impor- 
tant.     They  are  the  normal 
growth  of  the  pelvic  bones ,  the 
traction  which  ligaments  and 
muscles  exert  upon  the  devel- 
oping bones,  the  body-weight, 
the  upward  and  inward  pres- 
sure of  the  heads  of  the  femora,  and  the  cohesive  force  offered  at  the  symphysis 
pubis.     The  excess  or  deficiency  of  any  of  these  forces  will  modify  the  shape  of 
the  pelvis.     If  the  pelvic  bones  do  not  develop  normally  before  birth,  a  deformity 

will  result  which  will  be  a  form  of 
the  congenitally  contracted  pelvis; 
of  this,  the  Naegele  or  Roberts  pel- 
vis is  an  example.  The  body-ii'cight 
begins  to  exert  its  influence  only 
after  the  child  begins  to  sit  up. 
Then  the  weight  is  exerted  through 
the  spinal  column  down  through 
the  sacrum.  The  first  change  con- 
sists in  the  tilting  forward  of  the 
upper  part  of  the  sacrum  and  the 
pushing  outward  of  the  pelvic  brim. 
The  sacral  promontory  is  lowered 
and  approaches  the  symphysis 
pubis.  Resistance  is  offered  by  the 
sacro-iliac  ligaments,  so  that  the 
degree  of  depression  of  the  sacrum 
is  limited.  The  pelvis  then  tends  to 
rotate  around  a  certain  point  back- 
ward, but  the  sacro-sciatic  liga- 
ments which  fasten  the  tip  of  the 
sacrum  to  the  ischii  and  ischiac  spines  resist  this  force,  so  that  from  the  influence 
of  all  these  forces  there  results  the  curve  or  bend  at  about  the  middle  of  the  third 
sacral  vertebra.  This  concavity  distinguishes  the  adult  pelvis  from  that  of  the 
child  (Figs.  511  to  523).     If  there  were  nothing  to  oppose  this  rotation,  the  same 


Fig.  522. — Bony  Pelvis  of  a  Female  Child  of 
Two  Years.  {\  natural  size.)  —  (Author's  col- 
lection.) 


392 


PHYSIOLOGICAL  LABOR. 


shaped  pelvis  would  be  found  in  both  child  and  adult.  The  lateral  concavity  is 
much  greater  in  the  infant.  The  adult  pelvis  is  comparatively  widened,  since  the 
antero-posterior  diameter  is  lessened.  As  long  as  the  child  is  on  its  back  the  body- 
weight  exerts  no  influence.  If  it  were  not  for  the  posterior  ilio-sacral  ligaments, 
the  promontory  of  the  sacrum  would  press  against  the  posterior  surface  of  the 
symphysis  pubis.  But  the  posterior  part  of  the  innominate  bone  extends  beyond 
the  spinal  column.  The  ilio-sacral  ligaments  act  as  a  hinge  and  tend  to  spread 
out  the  innominate  bones,  but  this  influence  is  resisted  by  the  heads  of  the 
femora,  which  press  upward  and  inward.  The  innominate  bones  act  like  a 
two-armed  lever,  with  the  sacrum  as  a  fulcrum  and  the  two   forces — body- 


F*G.  S^Z-- 


-BoNY  Pelvis  of  a  Female  Child  of  Five  Years. 

collection.) 


(f  natural  size.)  —  {Author's 


weight  and  counter-pressure — exerted  through  the  heads  of  the  femora.  So 
the  iliac  bone  is  bent  just  in  front  of  the  sacrum,  thus  producing  the  transverse 
widening  of  the  superior  strait.  Another  force  is  the  cohesive  force  offered  by 
the  symphysis  pubis,  which  counteracts  the  tendency  of  the  ilia  to  flare  out. 
Certain  reported  cases  illustrate  the  effects  of  the  various  influences  noted 
above.  Gurlt  found  a  hydrocephalic  woman  who  had  always  lain  in  bed.  She 
was  thirty-one  years  old  when  she  died.  Her  pelvis  was  a  model  of  the  infantile 
type,  though  larger  in  size.  The  force  exerted  through  the  femoral  heads 
cannot  act  without  the  other  forces,  so  that  it  never  exists  alone.  Neither 
could  cohesion  offered  by  the  symphysis  pubis  act  alone.  Clinically  an  ex- 
ample of  body-weight   acting  alone  has  never  been  observed.     Theoretically 


THE  MUSCLES  OF   THE  PELVIS.  393 

it  would  indicate  a  split  symphysis  pubis  and  undeveloped  legs.  Freund, 
of  Strasburg,  experimented  with  a  cadaver,  which  he  suspended  by  the  tips 
of  the  ilia.  He  cut  apart  the  symphysis  pubis;  the  ilia  spread  out  while  the 
symphysis  gaped  widely.  Litzmann  observed  a  case  of  split  pelvis  in  which 
there  was  no  union  at  the  symphysis  pubis,  so  only  the  two  forces  acted — 
body-weight  and  counter-pressure  of  the  femora.  The  resulting  pelvis  was 
very  wide  posteriorly,  while  the  counter-pressure  of  the  femora  caused  the 
anterior  portions  of  the  innominate  bones  to  become  nearly  parallel.  The 
transverse  width  was  marked.  Hoist  saw  a  case,  that  of  Eva  Lank,  who  was 
born  without  lower  extremities ;  thus  the  counter-pressure  through  the  femora 
was  lacking.  The  patient  could  sit  up,  consequently  the  forces — body- weight 
and  cohesion  of  symphysis — were  exerted.  There  was  a  marked  flattening  of  the 
pelvis  and  a  widening  of  the  transverse  diameter.  The  absence  of  the  counter- 
pressure  of  the  femora  and  the  long-continued  pressure  upon  the  ischial  tuber- 
osities caused  the  innominate  bones  to  so  rotate  as  to  turn  their  crests  inward 
and  the  ischial  tuberosities  outward,  thus  producing  an  excessive  widening  of 
the  pelvic  outlet.  Somewhat  similar  changes  are  found  in  congenital  dislocation 
of  the  hip,  where  the  children  have  never  walked.  It  is  plain  to  see  that  any 
change  from  the  normal  in  the  action  of  the  forces,  or  in  the  condition  of  the 
parts  concerned,  will  result  in  a  deformity  of  the  pelvis  which  may  vary  from  a 
slight  to  an  extreme  degree.  All  these  facts  are  very  important,  and  especially 
practical  in  relation  to  deformed  pelves.  The  inferior  races  seem  to  be  charac- 
terized by  an  inlet  having  a  lessened  transverse  and  increased  conjugate  diam- 
eter. Whenever  a  fair-sized  average  has  been  made,  there  has  never  yet  been  a 
people  discovered  in  which  the  conjugate  measured  more  than  the  transverse 
diameter.  The  consensus  of  opinion  seems  to  point  to  the  fact  that  favorable 
conditions  of  nutrition  and  activity  lay  the  corner-stone  for  a  well-formed  pelvis. 
Functions. — The  functions  of  the  pelvis  are  to  form:  (i)  A  ring  by  means  of 
which  the  body-weight  is  transmitted  to  the  lower  extremities;  (2)  an  axis  which 
permits  the  movements  of  the  lower  extremities  upon  the  trunk;  (3)  an  attach- 
ment and  lever  for  powerful  muscles;  (4)  a  cavity  to  contain  the  delicate  pelvic 
organs;  (5)  a  bony  canal  for  the  escape  of  the  fetus  from  the  abdominal  cavity 
during  parturition;  (6)  and  to  assist  in  the  performance,  through  the  pelvic  floor, 
of  the  rectal  and  vesical  functions. 


2.  THE  SOFT  TISSUES  OF  THE  PELVIS.     SOFT  PARTS. 

Familiarity  with  the  bony  pelvis  alone  is  not  sufficient  for  the  obstetrician, 
but  he  must  study  the  pelvis  together  with  the  soft  tissues,  muscles,  ligaments, 
and  cellular  tissue  which  encroach  upon  the  pelvic  space  and  close  in  the  openings 
of  the  latter,  which  is  thereby  converted  into  a  basin-like  body.  The  blood- 
vessels, the  lymphatics,  and  the  nerves  also  demand  attention,  and,  finally,  we 
must  go  back  to  our  pregnant  uterus,  already  studied  under  pregnancy,  place 
it  in  position  at  the  pelvic  inlet,  and  carefully  consider  the  pregnant  and  par- 
turient tract  or  canal,  extending,  as  it  does,  from  the  fundus  of  the  uterus  above 
the  umbilicus,  to  the  edge  of  the  perineum,  which  latter  in  the  second  stage 
of  labor  may  be  distended  five  inches  below  the  coccyx. 

I.  Muscles. — By  the  presence  of  the  muscles  of  the  pelvis,  especially  the 
ilio-psoas  (Fig.  524),  the  transverse  diameter  of  the  inlet  is  made  smaller  than 
the  oblique.  This  is  one  cause  for  the  prevalence  of  the  oblique  position  of 
the  fetal  head  in  cephalic  presentations.  The  function  of  the  musculature  of 
the  pelvic  canal,  ilio-psoas,  obturator,  levator,  and  other  muscles,  is  mechanical 


394 


PHYSIOLOGICAL  LABOR. 


during  parturition.  They  protect  the  bony  pelvis  and  guide  the  presenting  fetal 
part  in  a  line  which  favors  its  expulsion ;  they  also  serve  as  cushions  on  which  the 
fetus  may  rest  and  avoid  injury  from  pressure.  The  muscles  of  the  pelvic  floor, 
especially  the  levator  ani  and  coccygeus,  during  parturition  are,  to  an  extent, 


RiGHT    CRUS    OF    DIAPHRAGM 
\ 


INTcRTRANSVERSALIS    M 


OUADRATUS    LUMBORUM    M 


LEFT    CRUS    OF    DIAPHHAOfc 


PSOAS    PARVUS    M 


SACRO-LUMBAR    LIGAMENT 
SUPERIOR    SACRO-ILIAC 
LIGAMENT 

PSOAS    MAGNUS    M 


RIGINS    OF    PSOAS    MAGNUS    M 
FTiOM    THS    TRANSVERSE 
PROCESSES    OF    THE 
LUMBAR    VERTEBR/E 

PSOAS    MAGNUS    M 
/ 
'^C  CREST    OF    ILIUM 

'*'m>\         PYRIFORMIS    M 


GRE*T   TROCHANTER  OF  FEMUR  \ 

LESSER    TROCHANTER    OF    FEMUR      / 
OBTURATOR    EXTERNUS    M 


OBTURATOR    MEMBRANE 


QUADRATUS    FEMORIS    M 


PECTINEO-FEMORAL    BAND    OF    THE    CAPSULAR 
LIGAMENT    OF    THE    HIP-JOINT 


Fig.  524. — The  Pelvic  Inlet    Seen    from   Above,  showing   the   Psoas   and    Iliacus 

Muscles. —  {Deaver.) 


passive.  Their  yielding  is  out  and  back,  and  they  are  often  lacerated  from  their 
resistance  to  the  presenting  part.  However,  the  direction  of  the  resistance  turns 
the  head  out  and  up  under  the  symphysis.  The  functions  of  these  latter  muscles 
are  to  give  support  to  the  viscera  of  the  pelvis,  complete  the  lower  end  of  the 
parturient  canal,  and  to  direct  the  presenting  part  to  the  orifice  of  the  vulva. 


THE  MUSCLES  OF   THE  PELVIS. 


396 


Psoas  Magnus  (Fig.  524). — The  psoas  magnus  is  long  and  fusiform  and  is 
situated  on  the  side  of  the  lunibar  region  of  the  spine  and  the  pelvic  brim.  It 
takes  its  origin  from  the  bodies,  transverse  processes,  and  intervertebral  sub- 
stances of  the  last  dorsal  and  all  the  lumbar  vertebrae,  and  is  inserted  into  the 
lesser  trochanter  of  the  femur  by  a  common  tendon  with  the  iliacus.  Its  action 
is  to  flex  and  rotate  the  femur  outward,  also  to  flex  the  trunk  and  pelvis  on 
the  thigh.  Obstetrically  it  acts  as  a  "bumper"  or  protection  between  the  fetus 
and  the  margin  of  the  pelvic  inlet;  it  diminishes  the  transverse  diameter  of 
the  inlet,  so  that  in  the  recent  state  the  oblique  diameters  become  the  longest, 
and  this  partly  explains  the  oblique  position  of  the  head  in  cephalic  presenta- 
tions. 

Psoas  Parvus  (Fig.  524). — The  psoas  parvus  is  long  and  slender  and  is 
situated  in  front  of  the  psoas  magnus.  It  takes  its  origin  from  the  bodies  of  the 
last  dorsal  and  first  lumbar  vertebrae  and  the  intervertebral  substance,  and 


URATOR    FASCIA 


OBTURATOa    CANAL 


iEVATOR   ANI    M 

FIBROUS  RAPHE 

OR    RECTO- 
COCCYGEAL  LIQ 


PYRIFORMI8    M 


Fig.  525. — Muscles  of  the  Female  Pelvic  Floor — Superior  View. — (Deaver.) 


is  inserted  into  the  ilio-pectineal  eminence  and  the  iliac  fascia.     Its  action  is 
to  make  tense  the  iliac  fascia. 

Iliacus  (Fig.  524). — The  iliacus  is  a  flat  muscle  filling  up  the  entire  internal 
iliac  fossa.  It  takes  its  origin  from  the  iliac  fossa,  the  inner  surface  of  the 
iliac  crest,  ilio-lumbar  ligament,  base  of  the  sacrum,  anterior  spinous  processes 
of  the  ilium  as  well  as  the  notch  included  between  them,  and  from  the  capsule 
of  the  hip-joint.  It  is  inserted  into  the  external  surface  of  the  tendon  of  the 
psoas  magnus.  Its  action  is  the  same  as  that  of  the  psoas  magnus.  The  psoas 
and  iliacus  flex  the  thigh  upon  the  pelvis  while  the}^  rotate  the  femur  out  ward : 
these  functions  are  performed  when  they  act  from  above.  From  below,  with  the 
femur  fixed,  the  lumbar  part  of  the  spine  and  the  pelvis  are  bent  forward  by  the 
action  of  the  muscles  of  both  sides.  By  them  also  the  erect  position  is  main- 
tained, since  they  support  the  spine  and  pelvis  upon  the  femur,  and  help  to- 
raise  the  trunk  when  the  bodv  is  recumbent. 


396 


PHYSIOLOGICAL  LABOR. 


Levator  Ani  (Fig.  525). — This  muscle  takes  its  origin  from  the  body  and  ramus 
of  the  pubis  posteriorly,  the  pelvic  fascia,  and  the  spine  of  the  ischium,  and  is 
inserted  into  the  tendinous  center  of  the  perineum,  the  sides  of  the  rectum  and 
vagina,  the  apex  of  the  coccyx,  and  a  fibrous  raph^  extending  from  the  coccyx 
to  the  anus.  There  has  been  much  contradictory  discussion  concerning  the 
comphcated  form  and  functions  of  the  levator  ani  muscle.  The  shape  of  the 
muscle  is  that  of  a  horseshoe.  It  acts  like  a  sling  which  is  anteriorly  attached 
to  the  pubes,  and,  passing  backward  in  a  horizontal  plane,  encircles  the  rectum 
and  vagina  (Dickinson)  Luschka  describes  it  as  the  diaphragm  of  the  pelvis, 
but  states  that  in  many  non-pregnant  women  it  is  almost  membranous;  we 
must  remember,  however,  that  there  is  always  a  hypertrophied  condition  of 
the  muscle  present  during  pregnancy.     Its  arrangement  consists  of  flat  bundles 


Fig.  526. — The  Parturient  Pelvic  Inlet  Seen  from  above,  showing  the  Narrowing 
OF  the  Transverse   Diameter  Caused  by  the   Psoas   Muscles. 


of  muscle-fibers  loosely  connected,  between  which  here  and  there  are  open- 
ings filled  up  with  connective  tissue  and  fat.  The  good  use  to  which  such  a 
structure  lends  itself  in  the  great  distention  of  delivery  can  easily  be  seen. 
The  depth  of  the  levator  in  woman  is  less  than  that  in  man,  corresponding 
with  her  shallower  pelvis;  while,  as  has  already  been  shown,  the  horizontal 
measurements  are  greater.  According  to  Henle,  the  longitudinal  muscle-fibers 
of  the  lateral  vaginal  walls  are  intertwined  with  the  fibers  of  the  levator  ani — 
an  arrangement  analogous  to  that  about  the  rectum.  The  division  of  the 
levator  which  reaches  to  the  front  of  the  rectum  is  a  very  narrow  band.  In 
shape  it  resembles  a  bow,  with  its  most  inferior  extremity  about  one-half 
inch  above  the  anus.  This  band  arises  at  the  outer  side  of  the  pubic  origin, 
crossing  over  the  larger  bundle  in  its  course.     This  part  of  the  muscle  in  women 


THE  MUSCLES  OF   THE  PELVIS.  397 

is  very  small  and  is  "collected  together  in  the  recto-vaginal  septum."  This 
fact  can  be  proved,  as  a  rule,  by  palpation.  The  connection  between  the  levator 
and  the  walls  of  the  rectum  is  very  intimate,  although  none  of  the  muscle- 
fibers  end  in  the  walls.  There  is  the  same  intimate  intermingling  with  the 
longitudinal  muscle-fibers  as  was  noted  about  the  vagina.  The  functions  of 
this  muscle  are  numerous  and  important:  (i)  During  the  internal  rotation 
of  the  second  stage  of  labor  the  levator,  together  with  the  coccygeus,  internal  ob- 
turator, and  trans  versus  perinei,  are  the  chief  causes  in  determining  the  anterior 
rotation  of  the  lowest  portion  of  the  presenting  part.  (2)  The  most  character- 
istic action  of  the  levator  is  to  draw  forward  toward  the  symphysis  the  anus 
and  perineal  body,  thus  directing  the  head  or  presenting  part  out  under  the 
symphysis,  and  relieving  the  strain  on  the  perineum.  (3)  In  the  female  the 
pubo-coccygeal  part  of  the  levator  ani  serves  the  purpose  of  a  sphincter  muscle 
of  the  vagina,  and  perhaps  of  the  urethra  after  the  collapse  of  the  vagina.  (4) 
It  antagonizes  the  diaphragm  in  its  action  on  the  pelvic  contents,  as  it  rises 
and  falls  with  it  in  deep  respiration.  When  the  abdominal  muscles  are  acting 
energetically,  this  muscle  yields,  enabling  the  pelvis  to  endure  a  greater  strain 
than  if  it  were  more  resistant.  When  the  tension  is  removed,  the  muscle  restores 
the  perineum  to  its  original  condition.  (5)  It  assists  in  the  formation  of  the 
pelvic  floor  and  supports  the  lower  end  of  the  rectum,  vagina,  and  bladder. 
According  to  Studdiford,*  the  levator  ani  does  not  form  a  sling,  but  is  more 
like  a  narrow  V  with  sides  slightly  convex  toward  the  median  line  A  band 
of  involuntary  muscular  fibers  seated  between  the  rectum  and  vagina  serves 
to  connect  the  two  portions  of  the  levator.  This  is  the  muscular  band  which 
may  be  felt  behind  the  posterior  vaginal  wall.  By  its  action  the  two  segments 
of  the  levator  ani  are  approximated,  so  that  the  vagina  is  forced  upward  behind 
the  pubis  while  the  rectum  and  coccyx,  and  probably  the  external  sphincters, 
are  drawn  forward.  Studdiford  attaches  great  importance  to  this  band  of 
smooth  muscle,  and  believes  that  by  its  automatic  action  the  levator  is  enabled 
to  furnish  continuous  support  to  the  pelvic  viscera. 

Obturator  Internus  (Fig.  525). — It  takes  its  origin  from  the  inner  surface 
of  the  obturator  membrane  and  the  posterior  osseous  edge  of  the  obturator 
foramen,  as  far  as  the  ilio-pectineal  line  above  and  the  sacro-sciatic  notch  behind; 
its  fibers  converge  and  form  a  tendon  which  passes  through  the  small  sacro- 
sciatic  foramen,  and  then  is  directed  downward  and  backward  to  be  inserted 
into  the  digital  cavity  of  the  great  trochanter.  Its  action  is  to  rotate  the  thigh 
outward;  to  assist  in  increasing  the  resistance  of  the  posterior  segment  of 
the  pelvic  floor;  to  act  as  a  bumper  and  protection  to  the  fetus.  Owing 
to  its  thinness,  this  muscle  does  not  materially  affect  the  dimensions  of  the 
pelvic  cavity. 

Pyriformis  (Fig.  525). — The  pyriformis  arises  by  three  digitations  from  the 
front  of  the  second,  third,  and  fourth  sacral  segments,  from  the  border  of  the 
great  sacro-sciatic  foramen  and  the  great  sacro-sciatic  ligament,  and  is  inserted 
into  the  upper  border  of  the  great  trochanter  after  having  passed  through 
the  great  sacro-sciatic  foramen.  Its  action  is  to  rotate  the  thigh  externally; 
it  helps  to  form  the  posterior  and  outer  wall  of  the  pelvic  cavity;  in  fact,  its 
action  is  the  same  as  that  of  the  obturator  internus. 

Coccygetts  (Fig.  525). — This  is  a  small,  triangular  muscle,  by  many  included 

in  the  description  of  the  levator  ani.     It  is  situated  in  front  of  the  small  sciatic 

ligament,  between  the  levator  ani  and  the  pyriformis.     This  muscle  takes  its 

origin  from  the  spine  of  the  ischium  and  radiates  its  fibers  in  the  form  of  a 

*  "  New  York  Medical  Journal,"  April  12,  1902. 


398  PHYSIOLOGICAL  LABOR. 

fan  and  is  inserted  from  the  tip  of  the  coccyx  to  the  lateral  surface  of  the  two 
lower  sacral  vertebras,  filling  up  the  open  space  behind  the  levator.  Its  action 
is  to  support  the  coccyx  and  to  close  the  pelvic  outlet  behind.  The  pelvic 
surface  helps  to  support  the  rectum,  while  externally  it  is  closely  connected 
with  the  lesser  sacro-sciatic  ligament.  This  muscle  assists  in  restoring  the 
coccyx  to  its  original  position  after  the  strain  of  parturition  or  defecation  is 
passed.  In  caudate  animals  it  is  strongly  developed  and  causes  lateral  move- 
ments of  the  tail. 

B ulbo-cavernosus  (Fig.  525). — This  muscle,  which  is  sometimes  misnamed 
the  sphincter  vaginas  or  constrictor  cunni,  is  analogous  to  the  lateral  half  of 
the  male  accelerator  urinse  muscle.  Analogous  to  the  role  of  the  coccygeus, 
which  completes  the  muscular  diaphragm  back  of  the  levator,  is  that  of  the 
bulbo-cavernosus,  which  aids  in  closing  the  space  between  the  ends  of  the 
horseshoe,  although  it  is  a  thin,  weak  muscle.  Each  bundle  takes  its  origin 
from  the  fascia  of  the  perineum  about  half-way  between  the  anal  sphincter 
and  the  ischia,  only  a  small  band  being  connected  with  the  sphincter  (Luschka). 
Anteriorly  the  ends  as  they  converge  divide  into  three  bands.  One  part  goes 
to  the  inferior  surface  of  the  corpus  cavernosum  of  the  clitoris,  another  passes 
to  the  posterior  surface  of  the  bulb,  and  the  third  mingles  with  the  mucous  mem- 
brane between  the  clitoris  and  the  orifice  of  the  urethra  (Henle).  The  action 
of  this  muscle  is  chiefly  seen  in  its  function  of  compressing  the  veins  of  the 
clitoris,  and  thus  increasing  the  turgidity  of  the  erectile  tissue  and  so  main- 
taining as  well  as  creating  erection  of  the  clitoris.  It  is  not  a  sphincter,  although 
by  means  of  its  pressure  inward  on  the  turgid  bulbs  the  vestibule  of  the  vagina 
may  be  made  smaller.  Unless  hypertrophied  it  cannot  be  discovered  by  pal- 
pation. 

Transversus  Perinei,  or  Ischio-bulbosus  (Fig.  525). — This  muscle  arises  from 
the  ascending  ischial  ramus  and  is  inserted  into  the  base  of  the  perineal  body, 
the  fibers  of  the  two  muscles  intermingling  at  this  point.  Its  action  is  to  make 
the  central  tendon  of  the  perineum  tense,  so  that  the  other  muscles  attached 
in  that  vicinity  may  have  a  fixed  point  from  which  to  act;  it  also  antagonizes 
the  action  of  the  levator  ani.  In  deep  perineal  laceration  the  two  muscles 
tend  to  produce  gaping  of  the  wound-,  and  interfere  with  union. 

External  Sphincter  Ani. — From  each  side  of  the  ano-coccygeal  ligament, 
just  beneath  the  superficial  fascia,  thin  sheets  of  striated  muscle-fibers  arise, 
and  passing  forward  blend  with  the  other  muscle-fibers  ending  in  the  perineal 
body,  thus  surrounding  the  anus  elliptically.  Its  fibers  are  interwoven  with 
those  of  the  bulbo-cavernosus  muscle.  Its  action  is  to  contract  the  skin  about 
the  anus;  to  assist  the  levator  ani  in  supporting  the  opening  during  the  strain 
of  defecation;  and  to  close  the  anus. 

2.  Ligaments  (Fig.  515). — The  sacro-sciatic  ligaments  number  four:  two 
posterior  and  two  anterior.  The  great  sacro-sciatic  ligament  arises  from  the 
posterior  inferior  iliac  spine  and  the  posterior  aspects  and  borders  of  the  sacrum 
and  coccyx,  and  is  inserted  on  the  internal  border  of  the  tuberosity  and  the 
ascending  ischial  ramus.  The  small  sacro-sciatic  ligament  arises  from  the 
borders  of  the  sacrum  and  coccyx,  and  is  inserted  into  the  ischial  spine.  The 
sacro-sciatic  ligaments  close  the  wall  of  the  pelvis  and  offer  protection  to 
and  direct  the  presenting  part.  The  obturator  membrane  closes  the  foramen 
and  acts  as  a  cushion  for  protection  of  the  presenting  part.  Besides  the  four 
sacro-sciatic  ligaments  there  are  the  anterior,  posterior,  and  lateral  sacro- 
coccygeal ligaments,  which  connect  the  sacrum  and  the  coccyx;  the  anterior, 
posterior,    and    superior   pubic   ligaments,    connecting   the    two    pubic    bones. 


LIGAMENTS,   CELLULAR   TISSUE,    VESSELS  AND   NERVES.    399 

These  ligaments  help  to  modify  the  shape  of  the  pelvis  and  the  direction  of 
its  axis,  as  well  as  to  act  as  buffers  for  the  presenting  part. 

3,  The  Pelvic  Cellular  Tissiie. — It  is  only  by  the  additional  support  afforded 
by  layers  of  fascia  or  by  a  mixture  of  fibrous  tissue  that  even  the  strongest 
muscle  can  resist  strain  that  is  prolonged.  The  pelvic  cavity  may  be  considered 
to  be  divided  into  two  spaces — peritoneal  and  subperitoneal — by  an  imaginary 
plane  which  passes  from  the  central  point  of  the  inner  surface  of  the  pubis  to 
that  point  where  the  third  and  fourth  sacral  bones  unite.  With  the  exception 
of  a  part  of  Douglas's  pouch  the  whole  pelvic  peritoneum  should  lie  above 
this  plane.  It  is  beneath  the  plane  in  the  intervals  between  the  pelvic  viscera 
where  are  the  blood-vessels^  lymphatics,  and  nerves,  as  well  as  fibrous  and  mus- 
cular tissue,  and  fibre-elastic  elements,  all  of  which  comprise  the  cellular  tissue 
of  the  pelvis.  The  proportions  of  these  different  elements  vary  according 
to  the  function  to  be  performed.  The  function  depends  to  a  certain  extent 
upon  the  situation  of  the  tissue.  When  investing  blood-vessels,  it  assists  in 
the  erectile  functions  of  the  venous  system  of  the  pelvis.  When  used  as  an 
attachment  for  organs,  it  becomes  more  ligamentous  in  character  and  helps 
to  preserve  the  mutual  relations  of  the  organs  which  it  helps  to  connect  as 
well  as  their  normal  position.  Some  parts  of  it  act  as  lines  of  traction  upon 
different  parts  of  the  uterus.  Parts  of  it  keep  in  contact  the  vaginal  walls, 
since  that  organ  is  not  only  drawn  backward  but  also  toward  the  side  of  the 
pelvis.  This  tissue  also  forms  part  of  the  uterine  system.  During  pregnancy 
this  tissue  is  greatly  hypertrophied  in  order  to  fill  the  space  that  is  left  vacant 
when  the  uterus  with  its  broad  ligaments  ascends.  After  delivery  the  excess 
of  tissue  is  gradually  absorbed,  and  the  uterus  and  its  ligaments  by  degrees 
return  to  their  normal  position.  This  tissue  surrounds  the  cervix,  and  from 
this  point  reaches  out  between  the  layers  of  the  broad  ligaments  to  the  wall 
of  the  pelvis.*  The  recto- vaginal  process  extends  between  these  two  organs 
down  to  the  pelvic  floor,  and  permits  of  the  changing  degrees  of  distensibility  of 
these  tubes.  The  vagino-vesical  process  is  found  between  the  superior  part  of 
the  anterior  wall  of  the  vagina  and  the  posterior  vesical  surface.  There  is  no 
such  deposit  of  connective  tissue  between  these  organs  in  the  lower  two-thirds 
of  the  vagina.  Since  the  amount  of  tissue  in  this  process  is  so  small  the  pelvic 
peritoneum  and  the  upper  part  of  the  anterior  wall  of  the  vagina  come  very 
close  together  when  the  bladder  is  empty — a  point  of  value  for  the  surgeon. 
The  rectum  and  the  sacrum  are  separated  by  a  little  connective  tissue. 

4.  Blood-vessels  and  Lymphatics. — The  blood-vessels  of  the  pelvic  floor 
consist  of  the  branches  directly  or  indirectly  derived  from  the  anterior  divi- 
sion of  the  internal  iliac,  together  with  the  veins  which  accompany  them; 
besides  these  there  are  numerous  plexuses  which  are  in  close  proximity  to 
the  vesico-vaginal  walls.  The  branches  of  the  inferior  pudic,  the  smaller  of 
the  terminal  branches  of  the  anterior  trunk  of  the  internal  iliac,  are:  inferior 
hemorrhoidal,  superficial  perineal,  transverse  perineal,  artery  of  the  bulb, 
artery  of  the  corpus  cavernosum,  and  dorsal  artery  of  the  clitoris.  The  sciatic 
with  its  branches  supplies  the  muscles  on  the  back  of  the  pelvis.  Besides 
these  the  inferior  vesical  and  vaginal  arteries  with  small  branches  from  the 
external  pudic  form  a  part  of  the  pelvic  blood-supply.  The  inferior  hemor- 
rhoidal and  the  superficial  perineal  arteries  supply  particularly  the  musculature 

♦Much  work  has  been  done  of  late  years  on  the  arrangement  of  this  pelvic  cellular 
tissue,  by  various  methods:  (i)  By  frozen  sections  and  pelves  hardened  in  spirit;  (2)  by 
injections  beneath  the  peritoneum  in  various  places  and  later  tracing  the  ramifications;  (3) 
by  water  injections;   (4)   by  plaster-of- Paris  injections. 


400  PHYSIOLOGICAL  LABOR. 

of  the  pelvic  floor.  The  superficial  perineal  artery  passes  through  the  super- 
ficial fascia  to  the  superficial  perineal  space  and  supplies  the  neighboring  struc- 
tures, giving  off  the  transverse  perineal  branch.  The  continuation  of  the  internal 
pudic  artery  lies  deeper,  being  between  the  two  layers  of  the  triangular  ligament. 
Here  the  arteries  of  the  vestibular  bulbs  and  of  the  crura  of  the  clitoris  branch 
off.  The  internal  pudic  artery  ends,  having  penetrated  the  anterior  layer 
of  the  triangular  ligament,  as  the  dorsal  artery  of  the  clitoris,  from  which  small 
branches  reach  the  corpus  cavernosum,  the  glans,  and  the  prepuce.  The  ovarian 
arteries  from  the  abdominal  aorta  pass  to  either  side  of  the  pelvis,  and,  running 
between  the  laminae  of  the  broad  ligament,  supply  the  ovaries  and  tubes,  one 
branch  passing  to  the  fundus,  another  traversing  the  uterus  and  there  anasto- 
mosing with  a  branch  of  the  uterine  artery.  The  latter  artery  passes  down 
from  the  anterior  trunk  of  the  internal  iliac  to  the  uterine  neck.  Ascending 
the  sides  of  the  uterus  one  branch  meets  the  ovarian,  and  one,  the  circular 
artery  of  the  cervix.  Incision  of  this  artery  or  rupture  causes  marked 
hemorrhage.  The  most  important  veins  are  the  tributaries  of  the  pudic 
vein  and  those  ha^ang  an  independent  course  forming  a  part  of  the  ves- 
ico-vaginal  and  hemorrhoidal  plexuses.  This  venous  supply  is  abundant. 
The  lymphatics  owe  their  chief  importance  to  their  relation  to  septic  ab- 
sorption. The  uterine  lymph-spaces  lie  between  bundles  of  connective  tissue 
and  are  covered  with  endothelial  cells.  These  finally  lead  to  the  thoracic  duct. 
The  glands  of  most  importance  are  the  sacral,  lumbar,  hypogastric,  obturator, 
inguinal,  and  uterine. 

5.  Nerves  (Fig.  155). — These  are  derived  principally  from  the  sym.pathetic 
system.  From  the  uterine  plexus  are  given  off  two  hypogastric  plexuses  from 
which  twigs  pass  to  the  uterus  and  ovaries.  To  the  perineum  are  distributed 
branches  of  the  internal  pudic  nerve  and  the  inferior  pudendal  branch  of  the 
small  sciatic.  The  pudic,  inferior  hemorrhoidal,  superficial  perineal,  deep 
perineal,  muscular  filaments  of  the  pudic,  and  dorsal  nerve  of  the  clitoris  are 
described  as  the  nerves  of  the  female  perineum. 

3.  THE  PARTURIENT  CANAL. 

Definition. — This  term  is  applied  to  the  cavity  of  the  uterus,  cervix,  vagina, 
and  vulva,  regarded  as  a  single  structure.  Many  obstetricians,  however,  restrict 
the  term  to  the  parts  which  lie  below  the  internal  os,  and  define  the  birth 
canal  as  the  dilated  passage  or  route  by  which  the  fetus  must  reach  the  external 
world  through  the  action  of  the  expulsive  forces  exerted  in  the  abdominal 
region.  The  present  conception  of  the  birth  canal  as  embracing  the  entire 
genital  tract  is  regarded  as  the  most  expedient.  The  term  parturient  canal, 
however,  does  not  apply  to  the  genital  passages  in  a  state  of  quiescence.  It 
is  present  then,  of  course,  in  a  potential  sense  only.  The  actual  canal  exists 
only  during  labor,  when  the  onward  progress  of  the  fetus,  together  with  the 
active  dilatation  and  resistance  offered  to  its  passage,  transform  the  distensible 
structures  into  an  anatomo-physiological  entity  which  has  its  own  individuality 
and  which  demands  a  careful  description.  A  knowledge  of  the  bony  pelvis, 
the  soft  parts,  and  the  changes  which  the  uterus  and  other  genitals  undergo 
during  pregnancy  is  requisite  before  proceeding  to  the  study  of  the  parturient 
canal. 

Formation. — At  the  end  of  pregnancy  the  uterine  cavity  is  distended  by 
the  mature  ovum  which  is  closely  united  to  the  external  membranes,  decidua, 
and  uterine  wall  (Fig.  137).     The  internal  os  is  tightly  closed  and  the  cervical 


THE  PARTURIENT  CANAL. 


401 


canal  as  well  (Fig.  138).  In. the  primigravida  the  external  os  is  likewise  closed 
and  but  slightly  patulous  in  the  multigravida.  (See  page  138.)  A  similar 
condition  of  stenosis  is  present  in  the  vagina  and  vulva.  The  potential  cavity 
now  consists  of  two  sections,  the  upper  of  which  is  represented  by  the  uterine 
cavity,  while  the  lower  comprises  all  the  parts  below  the  latter.  The  upper 
section,  already  distended  to  the  utmost,  will  dilate  no  more,  but  tends,  on 
the   contrary,   to   contract   upon    and   expel    its   contents,   thereafter  resuming 


a  i 


'PEBlTONrrM 


"-^"^  PERITONEUM 


Fig.  527. — Frozen  Section  after  Sudden  Death  from  Cerebral  Abscess  during 
THE  First  Stage  of  Labor.  Age  of  patient  thirty-seven  years;  7-para;  fiindus  uteri 
3  inches  above  the  umbiHcus;  internal  os  dilated  to  admit  two  fingers.  The  section 
shows  the  interior  of  the  left  half  of  the  uterine  cavity  with  placenta  and  membranes 
in  situ.  Note  that  the  internal  os  has  not  been  drawn  up  into  the  walls  of  the  uterus; 
the  beginning  formation  of  the  contraction  ring  just  above  the  plane  of  the  pelvic 
inlet,  and  that  the  rectum  is  impacted  with  feces. — {William  C.  Lusk's  case.) 


its  original  and  natural  state  of  closure.  The  lower  section,  on  the  other  hand, 
heretofore  in  a  state  of  natural  occlusion,  must  now  be  subjected  to  the  utmost 
degree  of  distention.  The  transformation  of  the  potential  into  the  actual 
cavity,  then,  affects  only  those  parts  which  have  no  active  function  of  con- 
traction. The  precise  line  of  demarcation  between  the  two  segments  of  the 
uterus — i.  e.,  the  functionally  active  and  the  functionally  passive — is  a  matter 
of  dispute.  It  was  formerly  assumed  that  the  internal  os  marked  the  boundary 
26 


402 


^PHYSIOLOGICAL  LABOR. 


between  the  segments,  for  in  the  state  of  quiescence  this  structure  appears 
to  indicate  that  the  first  act  of  labor  must  be  to  overcome  the  resistance  at 
this  point. 

Contraction  Ring. — According  to  modern  teaching,  the  very  first  step 
in  the  estabHshment  of  the  parturient  canal  is  the  formation  of  the 
so-called  contraction  ring,  in  the  uterine  wall  at  a  point  somewhat  higher 
up  than  the  anatomical  internal  os,  which  latter,  it  is  claimed,  is  of  no 
assistance  whatever  in  the  parturient  canal  (Figs.  527,  530).  This  contrac- 
tion I'ing,  which  often  goes  by  the  name  of   Bandl's  ring,  is  seated  at  a  point 


Fig.  528. — Frozen  Section  of  the  Uterus  and  Fetus  from  a  Primipara,  Aged  Twenty- 
four,  WHO  Died  Suddenly  from  an  Unknown  Cause  Two  Hours  after  Admis- 
sion to  the  Emergency  Hospital.  Labor  had  continued  twenty-four  hours,  and 
at  time  of  death  secondary  inertia  was  present.  The  cadaver  was  frozen  within 
twenty-four  hours,  and  the  section  made  forty-eight  hours  from  death.  The  caput 
succedaneum  is  distending  the  parturient  outlet,  and  the  head  Hes  upon  the  pelvic 
floor  in  the  left  occipito-anterior  position  before  anterior  rotation  of  the  occiput' 
(Compare  Figs.  529  and  530.) — {Dr.  W.  E.  Studdijord's  case  at  the  Emergency  Hospital.) 


in  the  uterus  opposite  a  large  coronary  vein,  and  at  which  the  serous  coat  of 
the  organ  adheres  intimately  to  the  subjacent  muscle  (Figs.  529,  530,  and  531). 
It  constitutes  a  wall-like  ridge  along  the  uterine  cavity  and  divides  the  latter 
into  two  segments,  known  as  the  upper  and  lower  uterine  segments,  which 
are  peculiar  to  the  parturient  canal,  having  no  existence  save  during  the  act 
of  labor  (Fig.  530).  The  transitory  existence  of  this  ring  gives  it  a  problematic 
character.  We  do  not  know  whether  it  is  always  the  same  in  different  uteri 
or  even  in  the  same  uterus  at  different  periods.  That  it  undoubtedly  exists 
has  been  shown  by  frozen  sections  of  women  dying  in  labor  (Figs.  531  and  532) 


THE  PARTURIENT  CANAL. 


403 


and  by  digital  exploration  during  labor,  while  its  existence  is  often  implied 
by  various  phenomena  during  parturition,  such  as  special  types  of  dystocia 
and  peculiar  forms  of  rupture  of  the  uterus.  It  is  by  no  means  certain  that 
those  uterine  fibers  which  lie  between  Bandl's  ring  and  the  site  of  the  internal 
OS  do  not  contract  to  some  extent.  Another  dubious  point  refers  to  the  possi- 
bility of  independent  contraction  of  the  ring,  most  obstetricians  holding  that 
this  contraction  is  necessarily  a  part  of  the  general  action  of  the  uterine  muscle. 
The  consensus  of  opinion  is  that  the  ring  is  non-existent  save  during  a  labor 
pain.  Veit,*  who  has  recently  written  at  length  upon  the  contraction  ring, 
claims  that  with  the  beginning  of  dilatation  that  part  of  the  uterus  which  is 


LOVER  BORDER 
OF  PERITONEUM 


CONTRACTION 
RINQ 


LUK 


Fig.  529. — Outline  of  Fig.  528  with  Explanatory  Titles. 


to  form  the  future  inferior  uterine  segment  is  distinctly  thinner  than  the  upper 
or  functionally  active  segment. 

Cervical  Dilatation. — The  labor  pains  acting  upon  the  amniotic  fluid 
which  invests  the  fetus  make  uniform  pressure  within  the  uterine  cavity. 
The  potential  cavity  of  the  cervix  is  naturally  the  locality  which  must  give 
way  by  a  process  of  dilatation,  and  the  amniotic  sac  with  its  fluid  is  forced 
into  this  cavity  in  a  wedge  shape.  With  the  inception  of  the  pains  the  mem- 
branes begin  to  separate  from  the  contractile  portion  of  the  uterus,  remaining 
adherent,  however,  below  the  site  of  the  actual  or  hypothetical  contraction 
ring.  This  separation  varies  in  kind.  Usually  it  occurs  between  the  layers 
of  the  decidua,  although  in  some  cases  the  detachment  occurs  between  the 
chorion  and  amnion.  Next  in  sequence  to  the  formation  of  the  contraction 
*  "  Monatschrift  f.  Geburts.  u.  Gynakol.,"  Feb.,  1900. 


404 


PHYSIOLOGICAL  LABOR. 


ring  and  dilatation  of  the  cervix  there  occur  certain  changes  throughout  the 
uterine  walls. 

Uterine  Walls. — As  the  cavity  of  the  uterus  begins  to  discharge  its 
contents  the  muscular  bundles  which  constitute  the  uterine  wall  undergo  a 
process  of  readjustment.  Lamellae  of  muscle  which  were  formerly  superimposed 
in  strata  now  come  to  lie  side  by  side,  with  resulting  thinning  of  the  uterine 
wall.  (Compare  Figs.  530  and  531.)  At  the  same  time  there  ensue  changes 
in  the  position  of  the  uterus.  The  latter  begins  to  move  backward  and  at 
the  same  time  to  ascend.  During  the  formation  of  the  birth  canal  the  fundus 
gradually  ascends  until  it  reaches  the  costal  arches,  and  synchronously  with 
this  ascent  there  is  also  a  slight  lateral  deviation,  usually  to  the  side  which 


Fig.  530. — Frozen  Section  seen  in  Fig.  528  with  Fetus  Removed.  Note  the  contrac- 
tion ring;  the  unruptured  membranes;  the  shape  of  the  parturient  tract,  including 
uterus  and  vagina,  and  the  thinness  of  the  lower  and  the  thickness  of  the  upper  uterine 
segments. — {Dr.  W.  E.  Studdiford' s  case  at  the  Emergency  Hospital.) 


is  opposite  to  the  fetal  back.  As  the  uterus  rises  the  contraction  ring  also 
ascends,  and  when  the  birth  canal  is  fully  formed  the  ring  should  be  nearly 
midway  between  the  symphysis  and  navel  (Figs.  527  and  529).  This  traction 
which  affects  the  upper  segment  and  ring  must  affect  the  lower  segment 
as  well;  but  as  the  cervix  is  held  fast  below,  the  lower  segment  must  undergo 
a  process  of  stretching.  In  the  primipara  the  dilatation  of  the  cervix  is  a  much 
more  laborious  process  than  in  the  multipara,  for  in  the  latter  much  less  resist- 
ance is  encountered  owing  to  the  semi-patulous  condition  of  the  external  os 
and  cervical  canal.  In  other  words,  the  multiparous  uterus  has  to  oppose 
chiefly  the  resistance  of  the  internal  os.  The  lax  walls  of  the  vagina,  abun- 
dantly moistened  by  the  natural  secretions,  offer  but  little  resistance  to  the 


THE  PARTURIENT   CANAL.  405 

fetal  head,  by  which  they  are  readily  separated.  In  primiparae,  however, 
the  degree  of  resistance  is  considerable.  The  maximum  of  opposition  is  found 
at  the  ostium  vagincB,  where  "the  distensibility  is  much  less  marked,  and  where, 
moreover,  additional  resistance  proceeds  from  the  active  contractions  of  the 
levator  ani  muscle.  This  resistance  is  gradually  overcome  by  the  advancing 
head,  and  is  always  much  greater  in  the  primipara,  causing  prolongation  of 
the  period  of  expulsion. 

The  completed  canal  or  tract  through  which  the  process  of  expulsion  takes 
place  is  irregular,  with  a  curved  axis  (Fig.  516);  the  successive  cross-sections 
vary  in  shape  in  a  definite  manner,  and  the  walls  of  the  canal  vary  in  rigidity 
at  the  various  segments.  This  canal,  when  completed  under  the  combined 
influence  of  the  active  uterine  contractions  and  the  passive  dilatation  of  the 
parts  below  the  contraction  ring,  may  be  divided  into  three  portions:  viz., 
(i)  suprapelvic,  (2)  pelvic,  and  (3)   infrapelvic. 

Suprapelvic  Portion. — The  suprapelvic  portion  consists  of  the  uterus,  and 
although  it  is  a  part  of  the  parturient  canal  mechanically  considered,  it  is  more 
especially  the  force  which  urges  the  fetus  on  than  a  part  of  the  passageway 
through  which  it  travels. 

Pelvic  Portion. — The  pelvic  portion  contains  the  cervico-vaginal  portion 
of  the  birth  tract.  During  the  elongation  of  the  uterus  and  dilatation  of  the 
OS  the  cervix  lies  within  the  pelvic  excavation.  The  custom  of  describing  the 
bony  pelvis  as  a  portion  of  the  birth  tract  does  not  appear  to  me  to  be  advisable 
(Fig.  516). 

Infrapelvic  Portion. — This  consists  of  the  distended  and  thinned  sacral 
segment  of  the  pelvic  floor  (Fig.  516).  When  the  utero-vaginal  portion  of 
the  birth  tract  has  been  formed  by  the  act  of  labor,  another  step  is  required 
for  the  completion  of  this  structure,  viz.,  elongation  of  the  pelvic  floor.  When 
the  head  of  the  child  is  upon  the  pelvic  floor,  the  latter  must  necessarily  go 
through  some  form  of  violent  alteration  in  shape  before  the  passage  of  the  fetus. 
The  capacity  of  the  floor  for  distention  is  limited.  But  these  changes  in  the 
pelvic  floor  are  not  wholly  effected  in  the  single  act  of  expulsion.  A  study 
of  this  structure  in  frozen  sections  and  otherwise  shows  that  there  are  natural 
differences  between  its  relation  in  the  non-pregnant  and  that  in  the  pregnant  at 
term.  While  in  the  former  the  pelvic  floor  projects  but  slightly  below  a  line 
which  passes  from  the  tip  of  the  coccyx  to  the  lower  border  of  the  symphysis, 
in  the  woman  at  term  the  perineum  is  already  relaxed  as  well  as  thickened 
by  oedema,  so  that  it  bulges  considerably  beneath  the  natural  level.  The 
ascent  of  the  uterus,  already  described  in  connection  with  the  formation  of 
the  utero-vaginal  portion  of  the  birth  tract,  tends  to  draw  upward  the  parts 
anterior  to  the  vagina;  so  that  the  fetal  head  does  not  force  them  below  the 
symphysis  (Fig.  573).  The  distensible  portion  of  the  pelvic  floor  is  therefore 
the  portion  posterior  to  the  vagina  known  as  the  sacral  segment  of  the  pelvic 
floor.  This  segment  appears  at  first  sight  to  be  thrust  forward,  and  at  the 
same  time  elongated  by  the  advancing  head.  But  a  study  of  lead-tape  tracings 
upon  the  pelvic  floor  during  labor  shows  that  the  soft  parts  are  really  forced 
backward,  and  at  the  same  time  excessively  thinned.  The  anus  is  moved 
backward.  The  pelvic  floor  projects  but  one  inch  in  the  non-pregnant.  At 
term  its  projection  is  2f  inches  (7  cm.),  and  during  labor  an  additional  inch 
is  added.  The  normal  perineum  is  i\  inches  (3.17  cm.)  long,  while  during 
complete  dilatation  it  measures  2^  inches  (6.35  cm.).  This  increased  projection 
of  the  floor  with  its  backward  displacement  and  elongation  appears  to  be  due 
entirely  to  the  thinning  of  the  sacral  segment  in  response  to  the  distention 


406 


PHYSIOLOGICAL   LABOR. 


Fig.  531. — Uterus  and  Vagina  from  a  Case  of  Sudden  Death  from  Eclampsia  near 
THE  End  of  the  Second  Stage  of  Labor.  Note  the  retraction  ring;  the  external 
OS,  the  thickness  of  the  uterine  walls  of  the  upper  and  lower  uterine  segments,  and 
the  region  of  the  internal  os. — {Author's  case  at  the  Emergency  Hospital.) 


THE  PARTURIENT   CANAL. 


407 


of  the  fetal  head.      While  the  perineum  is  almost  three  inches  in  thickness 
at  term,  it  is  but  an  eighth  of.  an  inch  thick  at  the  moment  of  expulsion. 


LEFT 
UTERINE, 
BLOOD 
VESSELS 


Pig    532.— Outline  of  Fig.   531   with  Explanatory  Titles 


Parturient  Canal  as  a  Whole.— This  structure  consists  of  an  actively  con- 
tracting uterus  in  the  shape  and  position  which  it  assumes  in  virtue  of  its  ascent 


408  PHYSIOLOGICAL  LABOR. 

in  the  abdominal  cavity;  and  the  passive  portions,  namely,  vaginal  and  vulval, 
which  complete  the  canal  and  form  a  pronounced  curve  with  a  short  anterior 
and  long  posterior  aspect  (Fig.  516).  The  former  is  equii^alent  to  the  anterior 
uterine  wall  and  the  posterior  surface  of  the  symphysis  plus  the  soft  parts 
which  lie  in  front  of  the  pubic  bone,  and  the  latter  to  the  concavity  of  the  pos- 
terior uterine  wall,  the  sacrum  and  coccyx  plus  the  stretched  and  elongated 
perineum.  If  each  of  these  surfaces,  the  shorter  anterior  convex  and  the  long 
posterior  concave,  is  divided  into  a  given  number  of  equivalent  segments, 
and  the  points  which  correspond  on  each  surface  are  cut  through  by  planes, 
an  imaginary  line  passing  through  the  center  of  each  of  these  planes  will  describe 
a  certain  curve  which  is  not  the  arc  of  a  circle  (Fig.  517).  This  curve  represents 
the  axis  of  the  birth  canal,  and  must  be  described  or  followed  by  the  center 
of  any  solid  mass  which  is  forced  through  this  passage.  Numerous  attempts 
have  been  made  to  represent  the  various  angles  of  inclination,  axes,  and  curves 
of  the  birth  tract,  but  a  total  lack  of  agreement  exists  in  the  views  of  obstetri- 
cians on  this  geometrical  problem.  In  1828  Carus  attempted  to  show  that 
the  parturient  axis  should  be  regarded,  for  practical  purposes,  as  the  arc  of 
a  circle,  the  center  of  which  was  represented  by  the  center  of  the  posterior 
surface  of  the  symphysis.  In  this  sense  Carus's  curve  was  understood  by 
Meigs,  Tarnier,  and  others.  But  Carus  states  himself  that  the  actual  curve 
is  not  the  arc  of  a  circle,  but  a  so-called  curve  of  the  higher  order,  such  as  form 
the  subject-matter  of  Cartesian  or  analytic  geometry.  He  intimates  that  he 
has  determined  the  formula  for  such  a  curve,  and  refers  the  reader  to  an  in- 
accessible work  upon  the  skeleton.  The  arc  of  a  circle  appears  to  represent 
the  curve  to  the  parturient  canal  in  the  drawings  attributed  to  Krause,  and 
Moreau  and  Jacquemier,  as  cited  in  Varnier's  analytic  study  of  labor.*  In 
addition  to  difference  of  opinion  as  to  the  parturient  curve,  authors  do  not  agree 
as  to  the  axis  of  the  parturient  uterus  and  superior  strait.  While  many  speak 
of  these  axes  as  one  and  the  same,  Faraboeuf  and  Varnier  regard  them  as  dis- 
tinct.    With  this  last  view  I  am  in  accord. 


II.  THE  FETUS. 

Although  it  is  now  well  known  that  during  parttirition  the  child  is  entirely 
inactive,  and  so  offers  itself  as  a  passive  factor  only,  nevertheless  certain  parts 
of  the  child  do  indirectly  exert  a  modifying  influence  on  child-birth.  Obstetri- 
cally  considered,  the  fetus  is  made  up  of  a  head  and  a  trunk,  and  constant 
reference  is  made  to  the  vertex,  occiput,  bregma,  brow,  and  chin  of  the  head, 
and  to  the  shoulders  and  pelvis  or  breech  of  the  trunk  (Figs  533  to  550).  While 
the  bulkiest  part  of  the  fetus  in  its  normal  attitude  or  posture  is  the  trunk 
(see  Attitude),  still  the  head  is  least  compressible,  and  so,  obstetrically,  is 
larger  than  the  trunk  during  the  passage  of  the  fetus  through  the  pelvis,  because 
it  offers  the  principal  resistance.  The  head  is  much  larger  in  proportion  to 
the  trunk  in  the  fetus  than  in  the  adult  (Fig.  545). 

The  Fetal  Head. — Because  it  is  least  compressible,  it  is  the  most  important 
factor  in  the  mechanism  of  labor.     Still,  it  is  yielding  to  a  certain  degree,  as  is- 
shown  by  the  change  in  shape,  which  varies  according  to  the  diameters  in  which 
the  compressing  force  is  applied.      (See  Moulding.)     The  fetal  brain  will  endure 
with  impunity  much  compression  and  change  in  shape  and  volume,  particularly  as 

*  "  Obst^trique  Journali^re,"  iqoo. 


THE   FETAL  HEAD. 


409 


regards  the  hemispheres.  The  solidity  of  the  bones  at  the  base  of  the  skuH  protects 
the  gangha  in  that  region.  At  term  the  shape  of  the  fetal  head  is  oval;  the  two 
parts  of  the  frontal  bone  are  not  closely  united  at  birth  and  the  incompressible 
base  and  the  compressible  vault  can  be  most  clearly  compared  by  making  a  section 
through  the  skull  parallel  with  the  coronal  suture  just  a  little  posterior  to  it 
and  passing  through  the  parietal  eminences  and  the  mastoid  processes  The 
bones  of  the  base  are  solid  and  compactly  ankylosed;  the  compressible  vault 
consists  of  flexible,  semi-cartilaginous  laminae,  which  are,  except  the  frontal 
bone,  united  to  the  base  and  to  each  other  by  membrane  alone  The  face 
of  the  child  as  compared  with  that  of  the  adult  is  remarkably  small  in  propor- 


roj^rA/^£LL£ 

Fig.   533. — Diameters  and  Landmarks  of  the  Fetal  Skull.     Lateral  Surface. 


tion  to  the  cranium.  The  lower  jaw  particularly  differs  from  that  of  the  adult ; 
there  are  no  teeth,  and,  the  ramus  being  short  and  oblique,  the  lower  maxilla 
approaches  closely  to  the  upper,  bringing  the  angle  of  the  chin  very  near  to  the 
center  of  the  forehead,  and  rendering  the  distance  from  the  tip  of  the  chin 
to  the  root  of  the  nose  not  more  than  i  J  to  i^  inches  (3.17  to  3.75  cm.). 

Regions  and  Protuberances. — The  occiput  is  the  region  of  the  fetal 
head  behind  the  posterior  fontanelle  including  and  surrounding  the  external 
occipital  protuberances  (Fig.  533).  The  vertex  is  the  region  between  the  an- 
terior and  posterior  fontanelles  and  is  bounded  laterally  by  the  parietal  pro- 
tuberances. The  bregma  is  the  anterior  fontanelle.  The  sinciput,  or  brow, 
is  the  region  immediately  in  front  of  the  bregma  and  including  the  anterior 
portions  of  the  two  primitive  halves  of  the  frontal  bones  (Fig.  533).     We  find 


410 


PHYSIOLOGICAL  LABOR. 


five  protuberances  upon  the  fetal  head  which  are  important  as  obstetric  bony 
landmarks.  The  occipital  protuberance  is  situated  at  about  the  middle  of  the 
occipital  bone  and  an  inch  posterior  to  the  posterior  fontanelle  (Fig.  535). 
The  parietal  protuberances  are  situated  at  the  center  of  the  parietal  bones  (Fig. 
533).     The  frontal  protuberances  are  situated  at  the  center  of  the  frontal  bones 

(Fig-  536). 

Bones. — The  bones  composing  the  vault  of  the  head  are  the  two  frontal,  two 

oca  PUT. 


J^^/Mf'S'.i'CA 


c?.' 


p^. 


N^i-. 


\      ' 
BITEMPORAL  f  ^: 


3y^tN.(e.25c. 


Fig.  534. — Diameters  and  Landmarks  of  the  Fetal  Skull.     Upper  Surface. 


temporal,  two  parietal,  and  the  occipital.  The  squamous  portions  of  the  fetal 
skull  form  such  small  parts  of  this  vault  that  they  need  not  be  considered  (Fig. 
533).  From  the  standpoint  of  obstetrics,  the  base  consists  of  an  incompressible 
bony  mass  comprising  the  face  and  inferior  maxilla,  ossification  being  further 
advanced  here.  The  compressible  vault  is  attached  behind  and  above.  Occa- 
sionally one  finds  supernumerary  bones  in  the  interparietal  space ;  they  are  caused 
by  irregular  ossification,  and  are  termed  Wormian  bones. 

Sutures. — The    membranous    portions    between  the  bones  constitute  the 


THE  FETAL  HEAD. 


411 


sutures,  which  are  named  according  to  the  bones  which  they  join  and  the  posi- 
tions which  they  occupy.  The  sutures  are  not  dovetailed,  but  are  separated 
one  from  another.  The  frontal  suture  unites  the  two  frontal  bones ;  the  coronal 
or  fronto-parietal  sutures  join  the  two  frontal  with  the  two  parietal  bones;  the 
great,  sagittal,  or  biparietal  suture  unites  the  two  parietal  bones;  and  the  lamb- 
doid  (deriving  its  name  from  the  likeness  of  its  shape  to  the  Greek  letter  A), 
or  occipito-parietal,  joins  the  occipital  and  the  two  parietal  bones.  Besides 
these  there  are  two  others :  the  temporal  or  squamous  sutures,  which  are  not 
factors  in  the  mechanism  of  labor,  and  cannot  usually  be  palpated  during  the 
process  of  the  same  (Figs.  534  and  536). 

FoNTANELLES. — The    point    where    two  or  more  sutures  meet  is  termed  a 

BREGMA 


EXTERNAL 
OCCIPITAL  PffOTUBEf^ANCf 

Fig.    535- — Diameters   and   Landmarks   of   the   Fetal  Skull.     Posterior   Surface. 


fontanelle.  There  are  two  principal  ones,  namely:  (i)  The  anterior  or  great, 
also  called  the  bregma  and  sometimes  the  sinciput;  this  space  is  diamond-  or 
kite-shaped,  and  is  found  at  the  point  of  junction  of  the  frontal,  coronal,  and 
sagittal  sutures.  It  persists  during  labor,  notwithstanding  its  somewhat  de- 
creased extent  caused  by  the  approach  of  the  cranial  bones.  Four  sutures 
run  into  it ;  it  averages  one  inch  in  diameter  and  varies  widely  in  size  in  different 
fetal  heads.  (2)  The  posterior  or  small  fontanelle,  triangular  in  shape,  is  found 
at  the  point  of  junction  of  the  lambdoidal  and  sagittal  sutures.  This  space 
does  not  persist  during  labor,  being  then  merely  a  depression  or  obliterated  by  the 
overlapping.of  the  occiput  by  the  parietal  bones.  Three  lines  of  sutures  run  into 
it.     Not  infrequently  by  reason  of  advanced  ossification  this  fontanelle  is  absent. 


412 


PHYSIOLOGICAL  LABOR. 


(3)  The  temporal  joiUanellcs  are  found  at  the  anterior  and  posterior  extremities  of 
the  inferior  border  of  each  parietal  bone  (Fig.  533).  They  are  irregular  in  shape 
and  resemble  somewhat  the  occipital  fontanelle,  and  may  possibly  be  mistaken 
for  it  during  labor  in  cases  of  lateral  obliquity  of  the  fetal  head  (see  Part  V). 

(4)  False  jontanelles  are  occasionally  seen  either  along  the  line  of  a  suture  or  in 
the  body  of  a  bone,  and  are  due  to  imperfect  or  irregular  ossification.  They  rpay 
be  mistaken  for  the  principal  fontanelles.  In  my  collection  of  34  full-term  skulls 
well-marked  false  fontanelles  appear  in  4  instances,  or  ii.i  per  cent.;  in  2)Z  pre- 
mature skulls  in  5  instances,  or  15.1  per  cent.  (Fig.  439). 

Movements  of  the  Fetal  Head  Upon  the  Spinal    Column. — Complete 
Flexion. — The  head  may  so  bend  upon  the  child's  chest  that  the  chin  and  sternum 


Fig.    536. — Diameters    and    Landmarks    of    the    Fetal    Skull.     Anterior  Surface. 


touch  each  other,  giving  the  condition  of  complete  flexion.  The  movement  of 
flexion  is  really  rotation  of  the  head  on  a  transverse  axis. 

Incom,plete  Flexion. — In  certain  cases  when  the  head  is  at  the  pelvic  brim 
and  in  the  third  or  fourth  vertex  position,  flexion  is  either  partly  or  entirely 
wanting.  Sometimes  this  condition  results  from  the  usual  forces  not  exerting 
their  normal  degree  of  action.  Imperfect  vertical  flexion  in  a  flat  pelvis  will 
be  referred  to  again  (Fig.  539). 

Com.plete  Extension. — Again,  the  head  may  be  bent  backward  so  that  the 
occipital  protuberance  touches  the  cervical  spines  without  doing  any  injury 
to  the  vessels  or  ligaments  of  the  neck  and  giving  the  condition  of  complete 
extension  (Fig.  539).  These  movements  are  believed  to  take  place  principally 
in  the  cervical  vertebras,  the  occipito-atlantoid  articulation  taking  little  or  no 
part  in  them.  Antero-posterior  motion  in  some  instances  certainly  amounts 
to  as  much  as  115  degrees.     The  term  incomplete  extension  explains  itself. 


THE  FETAL  HEAD. 


413 


Rotation. — The  occipito-atlantoid  articulation  furnishes  the  mechanism  for 
a  very  important  movement' — that  of  rotation ;  rotation  that  allows  the  vertex 
to  move  from  one  point  in 'the  pelvis  to  another,  and  yet  not  necessarily  re- 
quiring the  shoulders  to  follow  this  movement.  The  question  as  to  how  great 
a  degree  of  rotation  of  the  head  upon  the  spinal  column  may  take  place  with 
safety  to  the  child  has  been  the  subject  of  much  dispute  among  obstetricians. 
Most  of  them  agree  that  rotation  in  the  arc  of  a  circle  consisting  of  90  degrees 
may  occur  without  any  injury  to  the  child  (Fig.  539),  and  Tarnier  even  goes  so  far 


i 


»s 


#. 


EXTERNAL 

OCCIPITAL 

PROTUBERANCE 


Pjq_    237. — Diameters    and    Landmarks    of   the    Fetal    Skull.     Inferior   Surface. 

as  to  say  that  rotation  in  the  arc  of  a  semicircle  may  be  made  to  occur  without 
injury.  In  this  case  the  child's  face  would  look  directly  backward  over  its 
spinal  column.  From  experiments  with  fetal  cadavers  I  find  that  this  rotation 
or  torsion  is  not  confined  to  any  single  point  or  joint,  but  is  distributed  along 
the  upper  spinal  vertebra.  Ninety-degree  rotation  of  the  fetal  head  durmg 
labor  often  occurs  without  injury  to  the  neck.  Fig.  539  is  one  of  several  pho- 
tographs of  living  children  I  have  taken  within  an  hour  of  delivery  to  prove 
the  harmlessness  of  ninety-degree  rotation  of  the  fetal  head.  In  the  present 
case  a  hundred  degrees  was  easily  obtained. 


414 


PHYSIOLOGICAL  LABOR. 


Lever  Action  of  the  Fetal  Head. — The  head  is  not,  evenly  balanced  upon 
the  spinal  column.  It  forms  a  lever,  the  chin  end  of  which  is  the  longer,  the 
occipital  end  the  shorter,  so  that  this  anterior  or  chin  arm  tends  to  fall  when 
the  head  is  balanced  upon  the  condyles.  The  importance  of  this  fact  will  be 
more  manifest  when  the  mechanism  of  labor  is  discussed  (Fig.  578). 

Moulding. — The  result  of  the  pressure  of  the  birth  canal  upon  the  fetal 
skull  is  to  diminish  the  capacity  of  the  whole  cranium.  This  is  brought  about 
by:  (i)  The  approximation  and  overlapping  of  the  bones  of  the  vertex.  The 
bones  of  the  calvarium  are  not  merely  joined  by  membrane,  as  was  stated  before, 
but  there  is  considerable  opportunity  for  overlapping  under  pressure,  since  (a) 
they  ossify  late;  {b)  they  are  separated  by  sutures  and  fontanelles  which  permit 

of  overlapping;  (c)  and  they  are  so 
thin  as  to  admit  of  bending  and 
moulding.  Overlapping  in  the  pro- 
cess of  labor  always  takes  place  in 
a  systematic  manner.  The  parietal 
bones  overlap  the  frontal  and  the 
occipital  bones,  and  the  parietal 
bone  which  is  submitted  to  the 
greater  pressure — that  is,  always 
the  one  which  lies  posterior  in  the 
pelvis — slidesunder  its  fellow.  (2) 
The  cerebrospinal  fluid  is  squeezed 
out  of  the  head  into  the  spinal 
canal.  (3)  The  blood  is  also  forced 
out  of  the  cerebral  vessels,  to  a  cer- 
tain extent.  (4)  Then,  too,  the 
brain  substance  itself  in  the  fetus 
is  but  slightly  developed,  and  is 
therefore  capable  of  being  com- 
pressed and  moulded  to  a  consider- 
able degree  without  any  permanent 
damage  to  the  fetus.  As  the  fetal 
head  descends  lower  and  lower  into 
the  pelvis  it  becomes  subjected  to 
an  increasing  degree  of  compres- 
sion and  moulding.  Moulding  is 
further  assisted  by  the  hinge  pro- 
duced by  the  non-ossification  of  the 
triangular  portion  of  the  occipital 
bone  with  the  basilar  portion. 
Diameters  of  the  Fetal  Head  (Figs.  533  to  537)- — For  the  purpose  of 
judging  of  the  changes  of  shape  in  the  head,  and  of  comparing  the  head  with 
the  pelvic  dimensions,  there  are  numerical  measurements  of  certain  diameters 
of  the  fetal  skull.  Problems  in  the  mechanism  of  labor  concern  not  only  the 
size  but  the  shape  of  the  fetal  head,  and  these  are  best  understood,  studied, 
and  described  by  the  aid  of  diameters  and  circumferences  taken  at  different 
planes.  The  most  important  diameters  in  case  of  pelvic  deformity  are  those 
of  the  base,  since  they  are  incompressible.  But  those  to  be  dealt  with  in  the 
usual  case  of  labor  are  those  having  at  least  one  extremity  on  the  vault  of  the 
skull,  and  therefore  capable  of  being  shortened.  The  incompressible  diameters 
are  (i)  the  bimastoid;  (2)  the  bimalar;  (3)  the  bitemporal.     The  fetal   head 


Fig.  538. — Antero-posterior  Movements  op 
THE  Fetal  Head  upon  the  Body.  Complete 
flexion;  incomplete  flexion,  incomplete  exten- 
sion; complete  extension. 


THE    FETAL   HEAD. 


415 


diameters  include  (i)  the  occipito-mental ;  (2)  the  occipito-frontal ;  (3)  the  sub- 
occipito-frontal;  (4)  the  s'ub6ccipito-bregmatic;  (5)  the  biparietal;  (6)  the 
bitemporal;  (7)  the  bimalar;  (8)  the  bimastoid;  (9)  the  f ronto-mental ;  (10) 
the  cervico-  or  trachelo-bregmatic. 

I.  The  occipito-mental  diameter,  O.  M.,  5-^  inches  (14  cm.),  is  the  greatest 
distance  from  the  center  of  the  lower  margin  of  the  chin  to  a  point  on  the  pos- 
terior extremity  of  the  sagittal  suture. 


'^'^s**^.. 


Fig.  539. — Rotation  of  the  Fetal  Head  upon  the  Body.  The  illustration  is  from  one 
of  several  photographs  taken  of  living  children  within  an  hour  after  delivery  to  prove 
the  harmlessness  of  90  degrees  or  even  greater  rotation  of  the  fetal  head  upon  the 
body.  This  photograph  shows  no  degrees  rotation. — {Photograph  taken  by  the  author 
at  ike  Emergency  Hospital.) 


2.  The  occipito-frontal  diameter,  0.  F.,  4^  inches  (11.5  cm.),  is  measured 
from  the  apex  of  the  occipital  protuberance  to  the  root  of  the  nose. 

3.  The  suboccipito-frontal  diameter,  S.  0.  F.,  4f  inches  (11  cm.),  extends 
from  the  junction  of  the  neck  and  occiput  to  the  root  of  the  nose. 

4.  The  suhoccipito-bregmatic  diameter,  S.  0.  B.,  3|-  inches  (9.5  cm.),  is  meas- 
ured from  the  junction  of  the  nucha  and  the  occipital  bone  to  the  center  of 
the  anterior  fontanelle. 


416  PHYSIOLOGICAL  LABOR. 

5.  The  hiparietal  diameter,  BI  P.,  3I  inches  (9.5  cm.),  is  the  widest  distance 
between  the  parietal  protuberances. 

6.  The  bitemporal  diameter,  T.  T.,  3^  inches  (8.25  cm.),  is  the  distance  be- 
tween the  anterior  ends  of  the  coronal  sutures. 

7.  The  bimalar  diameter,  M.  M.,  3  inches  (7.5  cm.),  is  the  greatest  distance 
between  the  malar  tuberosities. 

8.  The  bimastoid  diameter,  3  inches  (7.5  cm.),  is  the  widest  distance  between 
the  mastoid  apophyses. 

9.  The  fronto-mental  diameter,  F.  M.,  3^  inches  (8.25  cm.),  is  measured 
from  the  summit  of  the  forehead  to  the  center  of  the  lower  margin  of  the  chin. 

The  mento-frontal  diameter  cannot  be  estimated,  as  the  frontal  bone  offers 
no  fixed  point  which  would  serve  as  one  extremity.  However,  an  approximate 
measurement  might  be  stated  to  be  about  3  inches  (7.5  cm.),  one-half  of  w^hich 
would  span  the  distance  between  the  glabella  *  and  chin. 

10.  The  cervico-  or  trachelo-bregmatic  diam,eter,  3f  inches  (9.5  cm.),  extends 
from  the  junction  of  the  neck  and  chin  to  the  center  of  the  anterior  fontanelle. 

These  are  average  measurements  taken  from  many  thousand  heads,  elim- 
inating as  far  as  possible  alterations  in  shape  due  to  mouldmg  of  the  head  in 
its  journey  through  the  pelvis,  for  even  after  easy  labors,  with  perfectly  normal 
vertex  presentations,  the  diameters  of  the  child's  head  after  delivery  will 
be  decidedly  different  in  relative  length  from  those  which  have  just  been  men- 
.tioned.  While  these  changes  in  length  are  usually  only  relative,  yet  they 
may  at  the  same  time  be  absolute,  chiefly  affecting  the  occipito-mental  and 
occipito-frontal  diameters.  These  are  increased  while  all  the  others  are  dimin- 
ished, especially  the  suboccipito-bregmatic  and  the  biparietal.  The  diameters 
are  of  value  in  that  they  indicate  the  circumference  of  the  plane  of  the  skull 
in  which  they  are  taken.  As  has  been  stated,  the  general  shape  of  the  head 
is  roughly  ovoid,  or  spheroidal,  so  that  a  reasonable  idea  may  be  obtained  of 
the  mass  under  comparison.  The  approximate  measurements  of  the  more 
important  diameters  of  the  fetal  head  for  ease  in  memorizing  and  for  practical 
purposes  may  be  stated  as  follows: 

Occipito-mental, 5^  inches   (14  cm.)  Fronto-mental, ...  3  J  inches   (  9  cm.) 

Occipito-frontal, 4^  inches  (11  cm.)  Biparietal,    3^  inches   (  9  cm.) 

Sub-occipito-bregmatic  .3^  inches   (  9  cm.)  Bitemporal 3^  inches  (8.25  cm.) 

Planes  and  Circumferences  of  the  Fetal  Head. — Again,  we  study 
the  shape  and  size  of  the  fetal  head  by  means  of  planes  or  cross-sections  cor- 
responding to  its  diameters,  in  the  same  way  as  we  study  the  pelvis  by  means 
of  horizontal  planes  at  different  levels. 

1.  The  occipito-mental  plane  (Fig.  541).  This  section  passes  through  the 
occipito-mental  and  biparietal  diameters;  its  shape  is  irregular  and  oval;  its 
circumference  is  the  greatest  circumference  of  the  fetal  head  and  equals  15 
inches  (38  cm.). 

2.  The  occip no- frontal  plane  (Fig.  543).  This  section  passes  through  the 
biparietal  and  the  occipito-frontal  diameters;  it  is  irregularly  oval  in  shape; 
its  circumference  is  13I  inches  (35  cm.). 

3.  The  sitboccipito-frontal  plane  (Fig.  542).  This  plane  passes  through  the 
bitemporal  and  suboccipito-frontal  diameters;  it  is  also  oval  and  irregular  in 
shape;  its  circumference  is  12  inches  (30  cm.). 

4.  The  suboccipito-bregmatic  plane  (Fig.  540).  This  section  passes  through 
the  biparietal  and  suboccipito-bregmatic  diameters.     This  plane  is  the  smallest 

*  Glabella,  "  the  space  between  the  eyebrows." 


THE  FETAL  HEAD. 


417 


of  all  the  head  planes;  is  nearly  circular  in  shape,  and  is  the  plane  which,  in 
normal  vertex  presentations  and  complete  flexion  of  the  head,  is  successively 
in  relation  with  all  the  pelvic  planes  from  the  inlet  to  the  outlet  of  the  parturient 
canal.  Its  circumference,  after  moulding  of  the  head,  is  ii  inches  (28  cm.)- 
A  study  of  these  cephalic  planes  and  circumferences  shows  that  the  circum- 
ference of  the  suboccipito-bregmatic  plane  is  the  smallest,  and  that  of  the 
occipito-mental   is   the   greatest   of   the   fetal   head    circumferences;  that    any 


OCCI PUT 


Fig.  540. — Line  of  Section  and  Shape 
OP  Suboccipito-bregmatic  Plane. 
— (Author's  lead-tape  tracing.) 


Fig.  541. — Line  of  Section  and  Shape  of 
Occipito-mental  Plane. — {Author's  Lead-tape 
tracing.) 


departure  from  the  normal  attitude  of  complete  flexion  of  the  head,  whereby 
the  head  is  partly  extended,  increases  the  circumference  of  the  presenting 
part  anywhere  from  11  to  15  inches,  according  to  the  degree  of  head  extension; 
thus  making  all  the  difference  between  an  easy,  normal  labor  and  complete 
obstruction  due  to  a  too  great  fetal  head  circumference  presenting. 

Trunk  Measurements. — The  measurements   of  the  trunk  are  unimpor- 
tant in  average-sized  fetuses,  because  all  the  diameters  are  compressible  and 
offer  little  obstacle  to  delivery   (Figs.   544  to  550). 
27 


418 


.PHYSIOLOGICAL  LABOR. 


1.  The  hisacromial  diameter,  A.  A.,  4I  inches  (12  cm.),  is  the  greatest  distance 
between  the  acromial  processes.     It  is  readily  compressible  an  inch. 

2.  The  bitrockanteric  diameter,  T.  T.,  3^  inches  (9  cm.)   is  the  widest  distance 
between  the  trochanters. 

3.  The  dorso-sternal  diameter,  D.  S.,  3I  inches  (9.5  cm.),  is  an  antero-posterior 
diameter  at  the  level  of  the  shoulders. 

4.  The  sacro-pubic  diameter,    2^  inches    (5.5   cm.),   is  the   antero-posterior 


OCCI  PUT 


OCCI  PUT 


SINCI  PUT 


Fig.  542. — Line  of  Section  and  Shape 
OF  SuBocciPiTO-FRONTAL  Plane. — {Au- 
thor's lead-tape  tracing.) 


Fig.  543. — Line  of  Section  and  Shape 
OF  Occipito-frontal  Plane. — Author's 
lead- tape  tracing.) 


diameter  of  the  fetal  pelvis.     Flexion  of  the  thighs  upon  the  abdomen  doubles  this 
diameter,  making  it  4^  inches  (11  cm.);  it  is  then  compressible  an  inch  or  more. 

5.  The  vertico-podalic  diameter,  V.  P.,  9^  to  10  inches  (24.13-25.4  cm.),  is  the 
length  of  the  fetal  ellipse,  and  is  the  greatest  distance  from  the  vertex  to  the 
breech. 

6.  The  bisacromial  circumference — namely,  a  circumference  corresponding 
to  the  bisacromial  diameter— is  13  inches  {zz  cm.)  (Fig.  547)-  This  is  compres- 
sible several  inches.  > 


THE   FETAL   TRUNK. 


419 


Planes  and  Circumferences  of  the  Fetal  Trunk. — The  bisacromial  plane 
is  oval  with  its  long  axis  transverse  (Fig.  547).  The  midplane  of  the  fetal  ellipse 
is  an  important  one,  and  but  rarely,  if  ever,  referred  to  in  works  on  obstetrics  (Fig. 
544).  It  is  a  plane  passing  through  the  center  of  the  fetal  body  and  including  in 
its  circumference  the  knees,  elbows,  and  umbilical  cord.  Its  shape  is  generally 
oval,  and  its  long  axis  antero-posterior  as  regards  the  fetal  body.  The  bitro- 
chanteric  with  extended  thighs  is  oval  with  a  longer  transverse  diameter  (Fig.  550). 
When  the  thighs  are  flexed  on  the  body  a  more  round  shape  obtains  (Fig.  549)- 


Fig.  544. — Lateral  Surface  of  the  Nor- 
mal Fetal  Ovoid,  or  Ellipse,  showing 
ALSO  the  Line  of  Section  (i,  2)  and  the 
Shape  of  the  Midplane  of  the  Fetal 
Ellipse. — {Author's  lead-tape  tracing.) 


Fig.  545. — Anterior  View   of  the  Nor- 
mal Fetal  Ovoid  or  Ellipse. 


Length  and  Weight  of  the  Fully  Developed  Fetus. — At  the  for- 
tieth week,  or  full  term,  the  total  length  from  heels  to  vertex  varies  from  18.9 
to  20.47  inches  (48  to  52  cm.);  the  vertex-coccygeal  length  being  about  one- 
half  of  this.  The  average  weight  is  6.60  to  7.92  pounds  (3000  to  3600  grams); 
males  weighing  somewhat  more  than  females  and  the  first  child  less  than  sub- 
sequent children,  this    progressive  gain  in   weight,  however,  being  true  only 


420 


PHYSIOLOGICAL  LABOR. 


till  the  fourth  or  fifth  child.  It  must  be  remembered  that  variations  in  the 
weight  of  the  mature  fetus  occur  from  6  to  12  pounds  (2700  to  5400  grams); 
in  very  rare  instances  12  pounds  (5400  grams)  has  been  exceeded,  and  weights 
up  to  20  pounds  (9000  grams)  have  been  observed. 

Attitude   or  Posture. — A  practical  point   in   connection   with  the  part  the 
child  plays  in  the  process  of  labor  has  to  do  with  (i)  the  manner  in  which  the 


Fig.  546. 


Fig.  548. 


Fig.  549. 


Figs.  546-549. — Fig.  546  Shows  the  Relation  of  the  Long  Head  Diameter  to  the 
Long  Shoulder  Diameter,  They  being  at  Right  Angles  to  Each  Other.  Fig. 
547  Shows  the  Shape  of  the  Bisacromial  Plane. — {Author's  lead-tape  tracing.) 
Fig.  548  Gives  the  Posterior  View  of  the  Fetal  Ovoid  or  Ellipse,  showing 
Lines  of  Section  of  Bisacromial  Plane  (3,  4)  and  Bitrochanteric  Plane  When 
THE  Thighs  are  Flexed  (5,  6).  Fig.  549  Gives  the  Shape  of  the  Bitrochanteric 
Plane,  when  the  Thighs  are  Flexed. — {Author's  lead-tape  tracing.) 


child  is  placed  in  the  uterus  as  regards  the  relationship  existing  between  its 
own  parts,  and  (2)  the  relationship  existing  between  it  and  the  uterus  and  pelvis. 
Attitude  or  posture  designates  the  relation  which  the  different  parts  of 
the  fetus  bear  to  each  other.  In  the  normal  attitude  the  body  is  flexed  upon 
itself,  rendering  the  back  arched  so  as  to  form  a  convexity  backward  (Fig.  545). 
It  has  been  shown  that  from  the  earliest  period  the  embryo  tends  to  curve 
upon  itself,  and  this  flexion  persists  throughout  intra-uterine  life  (Fig.  134). 
The  head  is  bent  upon  the  sternum;  the  forearms  are  crossed  or  are  near  one 
another  upon  the  chest ;  the  thighs  and  legs  are  flexed  so  as  to  bring  the  knees 


ATTITUDE   AND   PRESENTATION   OF   THE   FETUS. 


421 


near  the  elbows  and  the  feet  near  the  buttocks  or  breech;  the  dorsum  of  the 
foot  being  somewhat  flexed  on  the  leg  and  the  soles  of  the  feet  turned  a  little 
mward;  the  umbilical  cord  is  generally  found  in  the  space  between  the  arms 
and  legs,  although  it  may  be  wound  about  the  neck  or  body  of  the  child  from 
one  to  several  times  (Fig.  134).  This  is  the  attitude  of  the  later  months,  but 
in  the  earlier  months,  when  there  is  a  relatively  greater  amount  of  liquor  amnii, 
the  fetus  is  not  in  such  a  compact  mass,  nor 
are  the  extremities  so  near  one  another. 

The  Fetal  Ovoid,  or  Ellipse. — In  consider- 
ing the  whole  body  of  the  fetus,  it  may  be 
regarded  as  presenting  roughly  an  ovoid  mass 
which  is  made  up  of  two  parts,  head  and 
trunk,  both  of  the  same  general  shape — 
ovoid.  In  normal  mechanism  the  long  axis 
of  the  whole  mass  is  almost  parallel  with  the 
axis  of  the  birth  canal,  and  the  two  axes  of 
the  two  masses  respectively,  head  and  body, 
are  nearly  parallel,  one  to  the  other.  The 
trunk  and  breech  of  this  fetal  ovoid,  or  ellipse, 
are  bulkier  and  require  more  room  than  does 
the  head,  which  latter,  after  moulding,  is  com- 
paratively pointed  (Fig.  544).  It  must  also 
be  rememlDcred  that  the  fetal  ovoid  is  flat- 
tened from  side  to  side;  that  its  greatest 
transverse  diameter  is  an  antero-posterior 
one  at  about  its  center  or  midplane,  and 
measured  from  the  spine  to  the  region  of 
the  flexed  arms,  legs,  thighs,  and  the  coiled- 
up  cord  (Fig.'  544).  Attitude  is  caused  chiefly 
by  the  tonic  action  of  the  flexor  muscles,  for 
they,  being  the  stronger,  predominate  over 
the  extensors,  and  the  primitive  attitude  of 
the  embryo  persists.  The  shape  of  the  uterus 
also  offers  an  etiological  factor.  According 
to  Pajot's  law  of  accommodation:  "  When  a 
solid  body  is  contained  in  another,  if  the 
container  is  the  seat  of  alternate  movement 
and  rest,  if  the  surfaces  are  slippery  and  not 
angular,  the  contained  constantly  tends  to 
accommodate  its  form  and  dimensions  to  the 
form  and  capacity  of  the  container."  After 
delivery  a  child  will  be  seen  to  assume  natu- 
rally the  prenatal  attitude  and  yet  it  is  free 
to  move  in  any  direction.  Faulty  attitude 
during  labor  may  cause  many  complications, 
such  as  incomplete  flexion  or  bregma  presen- 
tation; brow  and  face  presentations;  lateral 
flexion  of  the  head  and  prolapse  of  arms,  legs,  and  cord. 
Part  V.) 

Presentation. — The  term  presentation  is  used  to  designate  that  portion  of 
the  child  showing  itself  most  prominently  at  the  os  uteri,  in  the  vagina,  or 
at  the  vulva,  or  it  is  the  relationship  of  the  long  axis  of  the  child  to  the  long 
axis  of  the  uterus. 


Fig.  550. — Anterior  View  of  Fetus 
WITH  Extended  Arms  and  Legs. 
Shows  line  of  section  (3,  4)  and 
shape  of  bitrochanteric  plane  when 
thighs  are  extended. — {Author's 
lead-tape  tracing.) 


(See  P'etal  Dystocia, 


422 


PHYSIOLOGICAL  LABOR. 


Table  of  Pelvic  and  Fetal  Measurements, 
internal  measurements  of  the  bony  pelvis. 


Antero-posterior 
Diameters. 

Oblique 
Diameters. 

Transverse 
Diameters. 

Circumferences. 

Inlet 

Middle  plane 

cavity,    . . 

Outlet,    .... 

of 

4j  in.    (ii   cm.). 

5  in.  (12.S  cm.), 
3f-4i    in.    (9.5- 
12  cm.). 

5  in.   (12.5  cm.). 
4 J  in.   (12  cm.). 

si  in.  (13.5  cm.). 

4f  in.  (12  cm.). 
4-J  in.    (11   cm.). 

16  in.  (40.5  cm,). 
18  in.  (45  cm.). 

Depth  of  the  true  pelvis  in  front  is  if  in.  (4  cm.) ;  posteriorly  4^  to  5  in.  (11.5  to  12,5 
cm.);  lateral  walls  3^  in.  (9  cm.).  These  measurements  of  the  bony  pelvis  are  lessened 
by  the  muscles  and  tissue  of  the  soft  parts  i  to  J  inch  (0.635  to  1.27  cm.). 

CLINICAL  MEASUREMENTS  OF  THE  PELVIS. 

Interspinal  diameter , (Fig,  203)  10     inches  (25.5     cm.) . 

Intercristal  diameter, (Fig.  204)  11     inches  (28        cm.) . 

Bitrochanteric  diameter, (Fig.   204)  12 J  inches  (31         cm.). 

External  conjugate  diameter (Fig.   206)  8     inches  (20.25  cm.). 

Right  and  left  external  obhque  diameters, (Fig.  205)  8 J  inches  (22         cm.). 

Diagonal  conjugate  diameter (Fig.   209)  5     inches  (12.5 

True  conjugate  diameter, (Fig.   214)  4^  inches  (11.5 

Transverse  of  inlet  diameter (Fig,   216)  5J  inches  (13.5 

Sacropubic  conjugate  of  outlet  diameter (Fig,  208)  4!  inches  (12 

Bisischial  diameter (Fig,  210)  4^  inches  (11 

External  circumference  of  pelvis 35i  inches  (88,75  cm,). 


cm.), 
cm.), 
cm.), 
cm.), 
cm,). 


FETAL  HEAD  MEASUREMENTS   (Figs,  533  to  537). 
Occipito-mental    diameter 5i  inches  (14 


cm,), 
cm,), 
cm,), 
cm.). 


Occipito-frontal  diameter, 4i  inches  (11,5 

Suboccipito-bregmatic  diameter zi  inches  (  9,5 

Biparietal  diameter, 3I  inches  (  9.5 

Bitemporal  diameter - 3i  inches  (  8.25  cm.). 

Bimastoid  diameter, 3     inches  (  7.5     cm.). 

Pronto-mental  diameter, .'3i  inches  (  8.25  cm.). 

Cervico-bregmatic  diameter, 3f  inches  (  9.5     cm.). 


Occipito-mental  circumference, (Fig-  54^)  ^5     inches  (38  cm.). 

Occipito-frontal  circumference, (Fig.  543)  13!  inches  (35  cm.). 

Suboccipito-f rental  circumference, (Fig-  542)  12     inches  (30  cm.). 

Suboccipito-bregmatic  circumference, (Fig,  540)  1 1    inches  (28  cm.), 

Biparietal  circumference (Fig,  540)  12     inches  (30  cm.). 

FETAL  TRUNK  MEASUREMENTS. 

Bisacromial  diameter 4f  inches  (12      cm.). 

Bitrochanteric  diameter 3^  inches  (  9      cm.), 

Dorso-stemal  diameter, .  .  .' 3f  inches  (  9.5  cm.), 

Sacro-pubic  diameter, 2 J  to  4^  inches  (5.5    to  1 1.    cm.) , 

Vertico-podalic  diameter, 9^  to  10  inches  (24,13  to  25.4  cm.), 

Bisacromial  circumference, 13  inches  {^z     cm.). 


PRESENTATION   OF  THE  FETUS.  423 

f  Vertex,   Bregma.     Brow,   Face. 
I    Cephalic   ■  \  ■^'t^rior    Parietal     Bone,    Posterior   Parietal 

"  I       Bone. 

t  Excessive  flexion. 
Classification       1     U.  Pelvic {  Breech. 

°^  \    III.   Trunk I  Shoulder. 

Presentations.      I    ..-„,.         ,  (  t.    ■,  ,         , 

IV.  Complicated |  Prolapse  of  cord;  one  or  more  arms  or  legs. 

f  Head  and  breech. 

V.  Multiple \  Two  heads,  two  breeches. 

[  Head  or  breech  and  shoulder  or  abdomen. 

Relative  Frequency. — The  frequency  of  vertex  presentations  is  96  per  cent. 
of  all  presentations;  the  pelvis  or  breech  presents  in  from  3  per  cent,  to  4 
per  cent,  of  all  cases;  face  presentations  occur  in  0.5  per  cent.;  shoulder  pres- 
entations in  0.5  per  cent.;  and  brow  presentations  in  0.25  per  cent,  of  all  cases. 

We  have  no  reliable  figures  to  offer  for  the  relative  frequency  of  complicated 
and  multiple  presentations. 

Causes  of  Frequency  of  Vertex  Presentations. — The  etiology  of  the  usual 
presentation, — the  vertex, — considered  the  normal  since  it  is  present  in  96  per 
cent,  of  all  cases  at  full  term,  is  readily  understood.  It  is  well  established 
that  the  head  is  generally  lower  than  the  breech,  even  from  the  very  first 
formation  of  the  liquor  amnii.  It  has  been  shown  that  in  the  early  months 
frequent  changes  occur  in  the  position  of  the  fetus  in  utero,  that  these  changes 
become  less  and  less  marked  as  full  term  approaches,  until  at  that  period  the 
proportion  of  head  presentations  far  exceeds  in  frequency  any  other.  According 
to  Churchill's  statistics,  head  presentations  occur  in  83  per  cent,  of  living  and 
only  53  per  cent,  of  dead  fetuses  at  seven  months.  Changes  from  other  pre- 
sentations to  the  vertex  are  more  frequent  than  the  converse,  and  a  shoulder 
is  more  often  changed  than  a  breech,  the  causes  being  the  shape  of  the  fetus 
and  uterus  and  uterine  contractions. 

In  175  miscarriages  (third  to  seventh  month)  I  found  the  proportion  of 
cephalic  and  podalic  presentations  equally  divided.  In  238  premature  children 
including  living,  still-born,  twins,  and  still-bom  and  macerated,  I  found  the 
following : 

Cases. 

Cephalic   (vertex)   presentation, 129  or  54.20  per  cent. 

Podalic  (breech)   presentation SS  or  23-12  per  cent. 

Shoulder  presentation, 7  or  2.95  per  cent. 

Not  noted  on  history, 47  or  19.23  per  cent. 

Total 238 

In  the  total  number  of  238  premature  children,  including  the  twenty  twin 
cases : 

Cases. 

Fetus  was  bom  living, 114  or  47.89  per  cent. 

Fetus  was  still-bom, 47  or  19.75  P^r  cent. 

Fetus  was  still-bom  and  macerated 43  or   18.07  P^r  cent. 

Condition  not  noted  on  histories, 34  or  14.29  per  cent. 

Total 238 

Vertex.  Breech.  Shoulder. 

Living  children 3i-5o  per  cent.  9.24  per  cent,  0.84  per  cent. 

Still-bom, 9-24  per  cent.  5. 88  per  cent.  1.26  per  cent. 

Still-bom  and  macerated, 8.82  per  cent.  (5.30  per  cent.  o       per  cent. 

This  last  table  shows  markedly  the  predominance  of  vertex  presentations 
in  fetuses  bom  alive  (31.50  per  cent,  vertex,  and  9.24  per  cent,  breech,  in  living 


424  PHYSIOLOGICAL  LABOR. 

fetuses;  moreover,  the  sharp  decHne  in  the  excess  of  vertex  presentations  over 
breech  when  a  still-born  or  still-born  and  macerated  fetus  obtains  (9.24  per 
cent,  vertex  and  5.88  per  cent,  breech  in  the  former,  and  8.82  per  cent,  vertex 
and  6.30  per  cent,  breech  in  the  latter). 

As  pregnancy  approaches  term  the  presentation  becomes  progressively  more 
and  more  stable,  and  particularly  so  in  primigravidae,  because  the  head  descends 
lower  in  the  pelvis,  and  the  abdominal  walls,  being  more  rigid,  prevent  move- 
ments to  any  extent.* 

Gravity  is  an  important  factor  in  determinmg  the  position  of  the  head  at 
the  cervix.  The  fetus  is  immersed  m  a  fluid  not  much  lighter  than  itself  (liquor 
amnii,  specific  gravity  i.oi).  With  these  conditions  the  effect  of  gravity 
will  depend  not  upon  the  position  of  the  center  of  gravity  of  the  child  when 
suspended  in  air,  but  upon  the  relative  specific  gravity  of  the  different  parts. 
Matthews  Duncan  proved  that  the  specific  gravity  of  the  head  is  greater  than 
that  of  the  headless  trunk. 

Other  causes  of  head  presentation  exist,  and  one  is  the  shape  of  the  uterine 
cavity  and  the  law  of  accommodation,  for  the  fetus  in  vertex  presentation 
takes  up  less  room  than  in  any  other  position.  Although  in  the  middle  third 
of  pregnancy  the  pregnant  uterus  is  nearly  round,  yet  in  the  last  third  it  becomes 
more  and  more  pear-shaped  or  pyriform,  with  the  broad  part  directed  upward 
and  the  tapering  extremity  downward.  In  the  study  of  the  fetal  ellipse  it 
has  been  seen  that  it  consists  of  a  bioad  extremity,  the  breech,  and  the  narrowed 
part,  the  head.  In  the  adaptation  of  the  fetus'  body  to  the  uterine  cavity, 
a  head  or  vertex  presentation  results.  Since  the  uterus  is  so  elastic  and  con- 
tractile, when  the  long  axis  of  the  child  lies  transverse  or  oblique,  uterine  action 
tends  to  make  it  parallel  with  the  long  axis  of  the  uterus,  accommodating  the 
bulky  breech  to  the  roomy  fundus  and  the  smaller  pointed  head  and  vertex 
to  the  narrowed  and  less  roomy  lower  uterine  segment. 

Reflex  action  on  the  part  of  the  child  plays  its  part  in  causing  the  head 
to  lie  lowest.  In  the  case  of  breech  presentation  the  sensitive  buttocks  and 
feet  are  constantly  exposed  to  the  jars  caused  by  movements  of  the  mother, 
as  well  as  to  the  augmented  uterine  contractions  of  the  lower  part  of  the  uterus 
caused  by  the  extreme  stretching  to  which  it  is  subjected  by  a  breech  in  the 
latter  part  of  gestation. 

The  intermittent  uterine  contractions,  which  increase  in  force  and  fre- 
quency as  gestation  advances,  help  in  securing  a  head  presentation,  assisted 
liy  the  shape  and  attitude  of  the  fetus  and  the  bulk  and  mobility  of  the 
fetal  head.  The  sum  of  the  force  of  intra-uterine  pressure  is  toward  the 
lower  uterine  segment,  and  hence  the  head,  being  mobile,  is  forced  down  in 
that  direction. 

Summary. — The  following  are  the  causes  of  vertex  presentation,  enumerated 
in  the  order  of  their  importance:  (i)  The  shape  of  the  uterine  cavity;  (2) 
the  shape  of  the  fetal  ellipse;  (3)  the  intermittent  uterine  contractions;  (4) 
the  mobility  of  the  fetal  head;  (5)  the  direction  of  intra-uterine  force;  (6) 
gravity;  (7)  reflex  action.  Alterations  in  the  normal  action  of  any  one  of 
these  important  causes  may  result  in  departures  from  a  normal  vertex  pres- 
entation The  shape  of  the  uterine  cavity  may  be  changed  by  tumors,  pelvic 
deformity,  low  implantation  of  the  placenta,  hydramnios,  and  multiple  preg- 
nancy.    The  normal  shape  of  the  fetal  ellipse  may  be  changed  by  hydrocephalus, 

*  Schroeder,  however,  from  observations  made  in  214  primigravidae,  including  four 
cases  of  contracted  pelvis,  found  during  the  last  three  weeks  of  pregnancy  changes  of  pres- 
entation occurring  in  36.4  per  cent. 


POSITION   OF   THE   FETUS.  425 

and  by  tumors  of  the  neck  and  trunk.     Gravity  and  reflex  action  are  affected 
by  the  death  of  the  fetus. 

Position. — The  term  position  is  used  to  define  the  relationship  existing 
between  a  certain  point  on  the  presenting  part,  and  certain  other  points  on 
the  pelvis  of  the  mother.  The  points  on  the  presenting  parts  are  the  occiput 
in  vertex  presentations;  the  sacrum  in  breech  presentations;  the  chin  in  face 
presentations;  the  frontal  bone  in  brow  presentations,  and  a  scapula  in  shoulder 
presentations  respectively.  The  four  fixed  cardinal  points  on  the  mother's 
pelvis  are  the  two  acetabula  in  front  and  the  two  sacro-iliac  synchondroses 
posteriorly  (Figs.  513  and  514).  The  positions  in  all  presentations  are  named 
numerically,  beginning  at  the  left  acetabulum  and  passing  to  the  right,  and 
thus  around  the  pelvis;  as  the  first,  second,  third,  and  fourth.  There  are, 
therefore,  four  positions  for  each  presentation,  according  as  the  single  point 
on  the  presenting  part  corresponds  to  one  of  the  four  cardinal  points  on  the 
motlier's  pelvis.  For  example:  in  the  right  mento-posterior  position  the  chin  is 
the  point  on  the  presenting  part,  and  the  right  sacro-iliac  synchondrosis  is  the 
point  on  the  pelvis  of  the  mother.     This  is  the  third  position  in  face  presentation. 


POSITIONS  OF  THE   FETUS. 
VERTEX  POSITIONS. 
L   Left  Occipito-anterior — Occipito  Lasva  Anterior,  L.  0.  A..  70  per  cent. 
II.   Right  Occipito-anterior — Occipito  Dextra  Anterior,  R.  0.  A.,  10  per  cent. 

III.  Right   Occipito-posterior — Occipito   Dextra   Posterior,  R.  O.  P.,  17  per 
cent. 

IV.  Left  Occipito-posteiior — Occipito  Lasva  Posterior,  L.  0.  P.,  3  per  cent. 

FACE  POSITIONS. 

I.   Left  Mento-anterior — Mento  Lseva  Anterior,  L.  M.  A.,  second  in  fre- 
quency. 

II.   Right    Mento-anterior — Mento    Dextra   Anterior,    R.    M.    A.,   third    in 
frequency. 

III.  Right  Mento-posterior — Mento  Dextra  Posterior,  R.  M.  P.,  most  common. 

IV.  Left  Mento-posterior — Mento  Laeva  Posterior,  L.  M.  P..  fourth  in  fre- 
quency. 

BROW  POSITIONS. 
I.  Left  Fronto-anterior — Fronto  Lseva  Anterior,  L.  F   A. 
II.   Right  Fronto-anterior — Fronto  Dextra  Anterior,  R.  F..  A. 
III.   Right  Fronto-posterior — Fronto  Dextra  Posterior,  R.  F.  P. 
1 V.   Left  Fronto-posterior — Fronto  Laeva  Posterior,  L.  F.  P. 

PELVIC  POSITIONS. 
T.  Left  Sacro-anterior — Sacro  Lseva  Anterior,  L.  S.  A.,  most  frequent. 
II.   Right  Sacro-anterior — Sacro  Dextra  Anterior,  R    S.  A. 

III.  Right   Sacro -posterior — Sacro    Dextra   Posterior,    R.    S.    P.,   second   in 
frequency. 

IV.  Left  Sacro-posterior — Sacro  Lseva  Posterior,  L.  S.  P. 

SHOULDER  POSITIONS. 
I.   Left    Scapula   Anterior — Scapula    Laeva   Anterior,    L.    Scap.    A.,    most 
frequent. 

II.  Right  Scapula  Anterior — Scapula  Dextra  Anterior,  R.  Scap.  A. 

III.  Right  Scapula  Posterior — Scapula  Dextra  Posterior,  R.  Scap.  P. 

IV.  Left  Scapula  Posterior — Scapula  Lseva  Posterior,  L.  Scap.  P. 


426 


PHYSIOLOGICAL  LABOR. 


In  Germany  two  positions  of  the  vertex  are  described:  The  first  vertex  position  (I 
Schadellage)  is  when  the  occiput  lies  to  the  left  side  of  the  pelvis,  and  the  second  vertex  posi- 
tion (II  Schadellage)  is  when  it  lies  to  the 
right.  The  Germans  consider  our  third 
and  fourth  positions  to  be  variations  of 
the  first  and  second.  In  France  four  posi- 
tions are  described,  as  with  us,  and,  in  ad- 
dition, right  and  left  transverse  positions, 
making  six  in  all.  In  England,  as  in  Amer- 
•  ica,  four  positions  are  described.     On  the 

Continent  of  Europe — namely,  in  France 
and  Germany — and  also  in  America  the 
right  oblique  diameter  of  the  pelvic  inlet 
starts  from  the  right  sacro-iliac  synchon- 
drosis and  the  left  from  the  left.  In  Eng- 
land, on  the  contrary,  the  reverse  obtains; 
namely,  the  right  oblique  diameter  ends 
^^^-—,  S't  the  right  ilio-pectineal  eminence,  and 

C^t**,^  ''.      ''-jj^^^^f  ^^^  1^^^  ^^  that. which  ends  at  the  left  emi- 

*'      '"^/^  ^^^1^  nence. 

These  are  facts  which  must  be  remem- 
bered in  reading  German,  French,  and 
English  works  on  obstetrics. 

Relative  Frequency. — In  all  pre- 
sentations, with  the  exception  of  the 
shoulder,  the  first  and  third  posi- 
tions most  frequently  obtain.  In 
other  words,  at  the  pelvic  inlet  the 
long  diameter  of  the  presenting  part 
lies  in  a  diameter  of  the  uterus  which 
corresponds  to  the  right  oblique  di- 
ameter of  the  pelvic  inlet,  with  the 
dorsum  of  the  fetus  directed  to  the 
left  and  anterior  or  to  the  right  and 
posterior.  In  vertex  presentations 
the  first  position  obtains  in  70  per 
cent,  of  cases,  the  second  in  10  per 
cent.,  the  third  in  17  per  cent.,  and  the  fourth  in  3  per  cent.  In  face  presenta- 
tions the  first  position  is  second  in  frequency;  the  second  position,  third  in  fre- 
quency; the  third  most  common, 
and  the  fourth  position  is  fourth  in 
frequency.  In  shoulder  presenta- 
tions the  first  position  is  most  com- 
mon. In  pelvic  or  breech  presenta- 
tions the  first  is  the  most  frequent 
and  the  third  is  second  in  frequency. 
Explanation  of  the  Frequency  of 
the  First  Vertex  Position. — The  an- 
terior part  of  the  cavity  of  the  uterus 
is  better  adapted  to  accommodate 
the  posterior  plane  of  the  fetus,  while 
the  posterior  part,  which  is  en- 
croached upon  by  the  prominent 
lumbar  vertebras,  is  more  fitted  to 
receive  the  anterior  part  of  the  fetal 

ellipse.     This  is  why  the  child's  back  most  usually  presents  anteriorly.     But 
if  for  any  reason  the  uterus  should  be  uniformly  pear-shaped,  and  not  be  pos- 


FiG.  551. — Axial  Torsion  of  the  Pregnant 
Uterus  and  Shape  of  the  Uterine  Cavity. 
Note  that  the  long  transverse  diameter  of  the 
uterus  corresponds  to  the  right  oblique  pelvic 
diameter,  thus  bringing  the  left  border  of  the 
uterus  and  the  fetal  back  (in  L.  O.  A.)  toward 
the  anterior  abdominal  wall.  (Compare  Figs. 
160  and  545-) 


Fig.  552. — Axial  Torsion  of  the  Uterus  and 
Shape  of  the  Uterine  Cavity. 


POSITIONS  OF   THE   FETUS.  427 

sessed  of  those  peculiarities  just  mentioned,  then  the  back  of  the  fetus  may  look 
to  the  back,  front,  or  either  side  (Fig.  551). 

We  know  that  the  longest  horizontal  axis  of  the  uterus  is  a  transverse  one; 
in  other  words,  that  the  uterine  cavity  in  the  latter  part  of  pregnancy  is  flattened 
from  before  back  (Fig.  137).  In  this  connection  also  the  torsion  of  the  uterus 
on  its  longitudinal  axis,  whereby  the  left  lateral  aspect  inclines  toward  the 
front,  must  be  taken  into  account  (Fig.  551).*  The  result  of  axial  torsion  is 
to  bring  the  roomy  transverse  diameter  of  the  uterus  into  coincidence  with 
the  right  oblique  diameter  of  the  pelvic  inlet.  A  glance  at  the  fetus  in  its 
normal  posture  (Figs.  544  and  545)  will  show  that  its  greatest  horizontal  diam- 
eter is  an  antero-posterior  one;  namely,  from  a  point  on  about  the  center  of 
the  curved  back  to  the  anterior  plane  formed  by  the  legs,  arms,  and  umbilical 
cord.  In  other  words,  as  frozen  sections  prove,  the  fetal  ellipse  is  flattened 
laterally  (Fig.  545).  This  is  true  for  all  presentations  with  the  possible  excep- 
tion of  the  shoulder.  From  this  it  will  be  readily  seen  that  accommodation 
or  adaptation  will  cause  the  largest  transverse  diameter  of  the  fetal  ellipse 
to  correspond  to  the  roomiest  horizontal  diameter  of  the  uterus.  Hence  the 
antero-posterior  diameter  of  the  fetal  ellipse  must  correspond  to  the  transverse 
diameter  of  the  uterus,  and  torsion  of  the  uterus  causes  this  latter  to  coincide 
practically  with  the  right  oblique  of  the  pelvic  inlet.  The  presence  of  the  two 
parts  of  the  bowel,  the  sigmoid  flexure  and  the  rectum,  through  which  the 
feces  so  often  pass,  is  sufflcient  to  account  for  the  oblique  position  of  the  pre- 
senting part,  whether  the  back  lies  anterior  or  posterior,  and  so  to  explain  the 
usual  positions — left  anterior  or  right  posterior. 

Although  the  transverse  diameter  of  the  bony  inlet  is  by  actual  measure- 
ment the  longest,  still  this  long  diameter  passes  just  in  front  of  the  promontory 
of  the  sacrum,  and  the  head  enters  the  plane  of  the  inlet  half-way  between 
the  symphysis  and  sacrum,  and  here  the  diameter  is  less  than  5^  inches  (Fig. 
514).  These  facts  account  for  the  head  lying  in  one  or  the  other  of  the  oblique 
diameters.  Another  factor  is  also  present,  and  that  is  the  encroachment  of 
the  muscles,  the  ilio-psoas  in  particular,  on  the  inlet  of  the  pelvis  (Fig.  546). 
This  makes  the  transverse  diameter  of  the  superior  strait  less  capacious  than 
the  oblique.  This,  too,  then  accounts  for  the  predominance  of  oblique  fetal 
positions  regardless  of  the  presentation.  It  has  been  determined  that  these 
muscles  decrease  the  transverse  diameter  by  about  1.5  cm.  (0.5906  inch)  and 
the  conjugate  by  i  cm.  (0.3937  inch).  The  most  frequent  positions  of  the 
fetus  therefore  are  the  first  and  third,  the  former  being  most  frequent  for  reasons 
stated  above. 

We  may  sum  up  the  causes  of  the  greater  frequency  of  the  first  and  third 
positions  as  follows:  (i)  The  flattened  shape  of  the  fetal  ovoid;  (2)  the  shape 
of  the  uterine  cavity;  (3)  the  axial  torsion  of  the  uterus;  (4)  the  shortening 
of  the  left  oblique  diameter  of  the  pelvis  by  the  sigmoid  and  rectum;  (5)  the 
diminution  of  the  transverse  diameter  of  the  pelvis  by  muscles  and  sacral  prom- 
ontory; (6)  the  greater  roominess  of  the  right  oblique  diameter. 

♦Various  causes  for  this  axial  rotation  have  been  suggested:  (i)  the  position  of  the 
descending  colon  and  the  sigmoid  flexure,  which  are  often  distended  with  fecal  matter; 
(2)  the  embryological  development  of  the  uterus;  (3)  the  fact  that  the  right  round  liga- 
ment is  shorter  and  more  highly  developed  than  its  fellow;  (4)  the  greater  frequency  of 
the  right  lateral  position  of  the  patient. 


428  PHYSIOLOGICAL  LABOR. 


III.  THE  EXPELLING  FORCES. 

The  expelling  forces  consist,  first,  of  the  voluntary  or  auxiliary  forces,  which 
include  the  anterior  and  lateral  abdominal  muscles,  diaphragm,  and  pelvic 
floor;  and,  second,  of  the  involuntary  forces,  which  consist  of  the  contractions 
of  the  uterus  and  of  the,  round  and  broad  ligaments. 

1.  The  Voluntary  or  Auxiliary  Forces. — (i)  Abdominal  Muscles  and  Dia- 
phragm.— The  abdominal  muscles  and  diaphragm  in  contracting  increase  the 
intra-abdominal  pressure  and  give  efficient  assistance  to  the  efforts  of  the  uterus. 
These  forces  come  into  play  with  the  second  stage  of  labor,  and  are  at  first 
almost  purely  voluntary,  but  later  on,  toward  the  end  of  the  second  stage, 
they  are  reflex  by  nature.*  This  increased  abdominal  pressure  tends  to  force 
the  uterus  with  its  contents  downward,  in  a  line  whose  direction  is  that  of  the 
axis  of  the  pelvic  inlet.  Action:  Their  action  is  as  follows:  In  the  process 
of  labor  the  patient  draws  a  deep  inspiration,  thus  flattening  the  diaphragm; 
the  glottis  is  closed  and  the  diaphragm  becomes  fixed  and  contraction  of  the 
abdominal  muscles  takes  place.  As  a  result  of  the  descent  of  the  diaphragm 
the  fundus  is  pressed  forward  so  that  the  uterine  axis  is  practically  in  line  with 
that  of  the  pelvic  inlet.  In  the  last  part  of  the  expulsive  period,  when  the 
pains  continue  for  several  seconds,  the  patient  is  forced  to  open  the  glottis 
for  breath;  the  abdominal  pressure  is  by  this  action  relieved  until  closure 
of  the  glottis  once  more  takes  place.  At  times,  when  the  pain  becomes  unen- 
durable and  the  patient  is  forced  to  cry  out,  the  glottis  is  again  opened,  so 
it  may  happen  that  in  the  course  of  one  uterine  pain  there  are  several  abdominal 
contractions.  Harvey,  experimenting  on  dogs,  and  de  Graaf  on  rabbits,  in 
order  to  show  that  the  fetus  is  expelled  by  the  "vis  uteri  propria,''  opened 
the  abdomen  at  term;  nevertheless  the  animals  expelled  their  young  without, 
of  course,  the  aid  of  the  abdominal  muscles.  Haller  has  seen  spontaneous 
expulsion  of  young  in  the  case  of  pregnant  females  a  short  time  after  death. 
(See  Post-mortem  Delivery.)  Harvey,  Smellie,  and  others  have  reported  cases 
of  spontaneous  labor  in  paraplegic  women.  Although  the  voluntary  and  reflex 
contractions  of  the  abdominal  muscles  are  not  an  indispensable  factor  in  labor, 
nevertheless  they  accelerate  the  expulsion.  It  is  undoubtedly  true  that  the 
application  of  forceps  is  often  necessary  on  account  of  the  feebleness  of  the 
effort  which  is  expended — for  instance,  in  women  with  hernia. 

I  have  repeatedly  observed  and  demonstrated  to  students  the  second  stage 
of  labor  terminated  without  the  co-operation  of  the  abdominal  muscles  at  all; 
still,  the  action  of  these  muscles  is  most  important  in  the  expulsion  of  the  pla- 
centa, especially  after  it  has  left  the  uterus.  It  can  be  clearly  seen  of  what  assist- 
ance also  the  abdominal  contractions  are  in  completing  the  birth  of  the  child  in 
breech  cases,  when  the  after-coming  head  has  passed  below  the  retracted  fundus. 

(2)  The  Vagina  and  Pelvic  Muscles. — At  term  the  musculature  of  the  vagina 
is  hypertrophied  to  a  considerable  extent  and  is  important  in  the  expulsion  of 
parts  of  the  ovum  that  can  be  acted  on  by  peristalsis.  The  period  when  its  action 
is  most  valuable  is  during  the  expulsion  of  the  placenta.  The  only  pelvic  mus- 
cles of  the  pelvic  floor  concerned  in  expulsion  are  the  levator  ani,  the  transversi, 
the  sphincters  of  the  vagina  and  of  the  anus.  Their  action  is  imperfectly  peri- 
staltic and  assists  the  muscle  of  the  vagina. 

2.  The  Involuntary  Forces,  or  Uterine  Contractions. — The  uterus,  during  the 

*  It  was  at  one  time  held  that  the  abdominal  wall  was  the  sole  cause  of  the  birth  of 
the  child;  later  it  was  taught  that  it  played  no  part,  but  Schroeder  showed  that  both  uterine 
and  abdominal  contractions  were  conceme'd  in  the  expulsion  of  the  fetus. 


THE  EXPELLING  FORCES. 


429 


Fig.  553. — Shape  of  the  Uterus  during  the 
Period  of  Relaxation. 


contractions  of  the  second  stage,  is  retained  in  its  position  by  means  of  the  round 
ligaments,  which  are  composed  chiefly  of  involuntary  muscle-fibers,  assisted  by 
the  muscular  part  of  the  broad  ligaments.  In  contracting,  the  round  ligaments 
tend  to  force  the  fundus  downward  and  forward,  and  by  their  action  on  the 
upper  part  of  the  uterus  they  are  one  factor  in  the  increase  of  intrauterine 
pressure.  After  the  uterus  has  been  raised  by  the  round  ligaments,  however, 
abdominal  pressure  can  act  to  better 
advantage. 

(i)  Involuntary.  —  Although  the 
uterine  contractions  have  no  depend- 
ence on  the  will, — i.  e.,  they  are  in- 
voluntary,— they  may  be  consider- 
ably influenced  by  the  brain,  as  may 
be  seen  by  the  effect  of  mental  emo- 
tions. 

(2)  Peristaltic. — Like  other  organs 
composed  of  non-striated  muscle,  the 
contractions  are  assumed  to  be  peris- 
taltic in  nature,  probably  passing  from 
the  Fallopian  tubes  down  to  the  cer- 
vix.   The  waves  succeed  each  other  so 

quickly  that  the  whole  uterus  is  in  action  at  the  same  time.  From  observations 
on  the  lower  animals  it  is  believed  that  the  direction  is  from  above  downward, 
and  the  uteri  of  rabbits  for  example,  being  of  a  long,  tubal  form,  act  just  like 
a  length  of  intestine.  It  is  the  general  belief  that  the  contraction  of  the  human 
uterus  is  not  peristaltic.  I  have  repeatedly  attempted  to  determine  this  point  in 
Csesarean  section  cases,  but  the  contractile  segment  was  so  instantaneously 
involved  that  no  peristaltic  wave  could  be  demonstrated. 

(3)  Intermittent.  —  The  contrac- 
tions are  intermittent ;  each  contrac- 
tion begins,  reaches  its  acme,  and  then 
subsides,  the  length  of  time  occupied 
by  one  "pain"  depending  upon  the 
stage  of  labor  in  which  it  occurs,  the 
average  duration  being  about  a  min- 
ute; the  variations  being  between 
thirty  and  sixty  seconds.  The  inter- 
val between  contractions  is  about 
thirty  minutes  at  first,  but  decreases 
to  between  two  and  three  minutes  at 
the  end  of  labor.  The  contractions 
are  rhythmical  in  their  intermission — 
there  is  an  approximate  regularity 
about  them,  In  this  respect  there  is 
a  variation  in  the  same  ratio  as  the 
During  labor  the  contractions  gradually  increase  in 
At  the  beginning  of  labor  the  duration  of  the 


Fig.  554. — Shape  of  the  Uterus  during  a 
Uterine  Contraction. 


length  of  the  single  pains. 

severity,  duration,  and  frequency. 

contractions  is  about  twenty  seconds.     Toward  the  end  of  the  second  stage  the 

duration  is  a  minute  or  more.     In  some  cases,  after  the  uterine  contractions  have 

continued  for  some  hours,  they  cease  for  a  corresponding  period,  after  which  they 

once  more  become  vigorous. 

{4)   The  normal  intermittence  in  the  course  of  the  contractions  is  a  most 


430  PHYSIOLOGICAL  LABOR. 

necessary  feature  for  the  welfare  of  both  mother  and  fetus.  The  latter  would 
succumb  to  asphyxiation  were  the  contractions  continuous,  and  the  mother  would 
not  be  able  to  endure  the  long  agony  were  it  not  alleviated  by  periods  of  rest. 
She  would  also  be  subject  to  much  injury  of  her  tissues,  and  rupture  of  the  uterus 
would  almost  surely  occur.  The  musculature  of  the  uterus  also  would  not  receive 
its  nourishment  and  it  would  lose  its  irritability.  This  alteration  of  work  and 
rest  in  the  uterus  has  its  analogue  in  the  action  of  many  other  organs, — e.  g.,  the 
heart,  intestines,  and  brain, — these  conditions  seeming  to  be  one  of  the  essential 
characteristics  of  living  organs. 

(5)  The  Uterus  Changes  in  Form  and  Position. — Changes  in  form  and  posi- 
tion of  the  uterus  are  also  associated  with  its  contractions.  Its  shape  becomes 
cylindrical  during  a  contraction;  the  longitudinal  and  the  antero-posterior 
diameters  are  increased  to  a  slight  degree,  while  the  transverse  is  distinctly 
decreased.  This  latter,  shortening  somewhat,  extends  the  fetus;  its  curvature 
is  lessened  and  thus  causes  an  increase  in  the  longitudinal  diameter,  causing 
partial  extension  of  the  fetal  ellipse.  The  effect  of  the  contraction  of  the  round 
and  broad  ligaments  on  the  uterus  has  been  noted  on  page  429  (Figs.  553  and 

554). 

(6)  Proportionate  to  the  Resistance. — The  force  of  contractions  increases 
with  the  advancement  of  labor;  the  length  of  the  contractions  increasing  as 
the  length  of  the  interval  decreases.  The  pain  caused  by  contraction  against 
resistance  is  generally  proportionate  to  the  resistance,  though  not  invariably 
so,  for  in  primiparae  in  whom  there  is  great  resistance  this  state  is  usually  coun- 
terbalanced by  the  superior  quality  of  the  uterine  musculature.  The  opposite 
conditions  are  present  in  multiparse.  In  the  second  or  third  labor  conditions 
bear  a  more  favorable  relation  to  each  other  than  at  any  other  time. 

(7)  Vary  with  the  Presentation. — The  character  of  the  contraction  varies 
with  the  presentation.  In  vertex  presentations  the  contractions  possess  more 
regularity  and  efficiency,  and  may  even  be  termed  characteristic  of  normal 
labor;  in  face,  brow,  breech,  and  shoulder  presentations  irregularities  are  usually 
manifest,  so  that  the  physiognomy  of  labor  is  well  worth  a  careful  study.  For 
in  order  to  obtain  normal  characteristics  there  must  be  uniform  pressure  on 
the  lower  uterine  segment  and  the  os,  and  this  is  not  exerted  in  breech,  face, 
brow,  or  shoulder  presentations;  hence  the  facies  in  labor  will  often  give  the 
keynote  to  the  presentation. 

(8)  The  Pain  of  Uterine  Contractions. — The  contractions  are  painful,  this 
being  their  most  striking  characteristic.  It  has  given  rise  to  the  term  "labor 
pain."  It  is  a  well-known  fact  that  in  the  majority  of  cases  the  first  pain  occurs 
between  ten  and  twelve  o'clock  at  night.  The  cause  is  not  known.  As  to 
the  character  of  the  pains,  it  differs  with  the  stage  of  labor  in  which  the  pain 
occurs.  They  are  at  first  quick,  sharp,  and  colicky,  and  are  due  chiefly  to  the 
dilatation  of  the  cervix,  and  are  felt  usually  in  the  sacral  region,  where  pain 
originating  in  the  cervix  is  almost  invariably  referred.  After  the  os  has  been 
dilated  they  become  "bearing  down"  in  quality,  and  are  then  efficient  in  ex- 
pelling the  fetus.  As  to  the  intensity  of  the  pains,  that  will  depend  on  the 
nervous  constitution  of  the  patient.  They  are  generally  more  severe  in  prim- 
iparae, especially  during  the  stretching  of  the  vagina  and  vulva.  Pain  is  also 
caused  by  resistance  of  the  brim,  and  by  the  strain  to  which  the  attachments 
of  the  uterus  are  subjected.  To  this  is  added  the  pressure  by  the  heavy  uterus 
on  the  nerve  plexuses  in  the  pelvis,  and  that  on  the  nerves  of  the  vagina  by 
the  presenting  part.  The  abdominal  muscles  also  are  the  seat  of  pain  on  account 
of  their   contractions,    which   are   cramp-like.     Pain   is   also   probably   caused 


THE  ETIOLOGY  OF  LABOR.  431 

by  compression  of  the  ends  of  the  nerves  which  He  between  the  contracting 
fibers.  Werth  advances  the'  suggestion  that  another  cause  is  spinal  neuralgia 
resulting  from  the  anemic  condition  of  the  lower  cord  and  meninges. 

(9)  False  Contractions  or  Pains. — These  are  contractions,  sometimes  pain- 
less, at  others  very  painful,  which  are  generally  localized  in  the  abdomen,  and 
as  a  rule  take  place  in  multiparas.  They  occur  a  short  time  before  labor  begins 
and  generally  in  the  early  hours  of  the  night.  They  have  no  effect  in  causing 
dilatation  nor  are  they  accompanied  by  the  "  show." 

(10)  Pulse  and  Arterial  Tension. — There  is  an  increase  in  pulse-rate  during 
a  uterine  contraction,  but  it  gradually  decreases  at  the  close.  Arterial  tension 
is  increased  on  account  of  the  amount  of  blood  that  is  driven  from  the  uterus 
to  the  general  circulation.  Respiration  grows  less  frequent  during  a  pain, 
but  increases  in  the  intervals.  The  temperature  of  both  uterus  and  body  is 
a  little  increased  during  a  contraction. 

Strength  0}  Uterine  Contractions. — Schatz  *  found  that  the  pressure  on  the  dynamometer 
was  20  mm.  mercury,  while  15  mm.  of  this  are  due  to  the  weight  of  the  fluid.  At  the 
height  of  the  contraction  it  ranged  to  100  mm.  Considerable  resistance  has  to  be  over- 
come by  the  uterine  contractions.  If  we  measure  the  amount  of  force  necessary  to  rupture 
the  membranes  outside  the  body,  we  will  have  an  approximate  estimate  of  the  force  of 
the  contractions.  Matthews  Duncan's  work  was  carried  on  with  a  piece  of  membrane 
about  4  inches  in  diameter  placed  over  a  cylinder  connected  with  an  anemometer.  His- 
results  varied  from  5  to  37  pounds  (2100  to  17,000  grams).  In  some  cases  a  force  equal 
to  the  mere  weight  of  the  fetus  accomplished  the  rupture ;  in  others  considerable  force 
was  reqtdred.  Polaillon's  tneihod:  In  this  the  surface  of  the  membranes  was  estimated 
as  217  square  inches  (1400  sq.  cm.).  Pressure  exerted  by  the  uterus  amounts  to  338.8 
pounds  (154  kilos),  88  of  which  are  due  to  uterine  contractions  and  the  rest  to  the  weight 
of  the  fetus.  Another  method  gave  him  the  force  of  each  pain  as  19.8  pounds  (9  kilos), 
and  for  the  whole  labor  965.8  pounds  (439  kilos).  Duncan  estimated  that  the  force 
in  a  whole  labor  was  40  or  50  pounds  (18  to  22  kilos),  and  the  effort  which  must  be  made 
to  hold  back  the  head  gives  these  figures.  He  also  estimated  the  amount  of  force  which  a 
child  can  endure,  and  found  that  there  was  no  change  till  90  or  100  pounds  was  reached. 
After  this  the  cervical  vertebrae  are  dislocated  and  30  pounds  (about  14  kilos)  more  will 
sever  the  head.  Hence  the  force  in  labor  must  be  less  than  this  figure.  In  his  estimations 
Poullet  made  use  of  the  tocograph,  and  Dr.  Henry  Leaman,  of  Philadelphia,  invented  an 
instrument  which  he  called  the  parturiometer,  for  measuring  the  force  of  uterine  con- 
tractions. This  last  instrument  I  experimented  with  for  two  years,  but  was  never  able 
to  arrive  at  any  satisfactory  conclusions. 


IV.  THE  ETIOLOGY  OF  LABOR. 

There  is  a  fatty  degeneration  on  the  surface  of  the  placenta  which  supervenes 
near  the  end  of  gestation  in  many  cases,  but  this  is  not  constant.  Eventually  the 
ovum  becomes  a  foreign  body.  This  theory  was  advanced  by  Naegele  and  others, 
and  the  view  appears  to  be  a  rational  one.  Eden  regards  all  the  changes  in  the 
placenta  as  senile  which  finally  cause  it  to  become  a  foreign  body.  Leopold  found 
marked  thrombosis  of  the  vessels  in  the  decidua.  He  considered  that  this  finally 
causes  an  increase  in  carbonic  acid  which  soon  causes  contractions.  Some  believe 
that  when  the  uterine  musculature  is  completely  developed  labor  begins,  but  we 
see  uterine  contractions  in  abortion  and  premature  labor.  Still  another  view  is 
that  after  the  uterus  has  been  distended  to  a  certain  extent  there  comes  a  reaction, 
and  the  process  of  retraction  begins  and  the  fetus  is  expelled.  But  this  does  not 
clear  up  the  matter,  since  the  thickness  of  the  uterus  varies  in  different  subjects 
and  in  the  same  subject  in  different  pregnancies.  Then,  too,  the  uterus  is 
distended  by  hydramnios  and  multiple  pregnancies  far  more  than  in  normal 

*  The  instrument  used  by  Schatz  was  called  the  tocodynamometer. 


432  PHYSIOLOGICAL  LABOR 

pregnancy,  and  still  the  general  rule  holds  good  that  the  fetus  is  bom  when 
it  becomes  mature — not  before,  not  afterward.  Spiegelberg  advances  the 
explanation  that  certain  substances  in  the  maternal  blood  which  in  the  early 
part  of  pregnancy  the  fetus  has  made  use  of,  accumulate,  since  the  nearer  the 
fetus  comes  to  maturity,  the  less  use  it  has  for  these  same  substances.  As 
it  reaches  the  point  of  maturity  and  needs  other  forms  of  nutrition  which  it 
is  now  unable  to  obtain,  this  fact,  as  well  as  the  accumulated  material  in  the 
mother's  blood  which  acts  upon  the  motor  centers  of  the  uterus,  militates  for 
its  speedy  expulsion.  Since  Braxton  Hicks  published  his  observations  on  the 
constant  contractions  of  the  uterus,  these  various  theories  have  been  less  con- 
vincing. He  claimed  that  the  contractions  take  place  after  the  uterus  appears 
above  the  symphysis  pubis,  and  during  labor  these  contractions  are  accentuated. 
The  function  of  these  contractions  in  pregnancy  is  not  known,  but  at  the  end 
of  pregnancy  they  expel  the  fetus  from  the  uterus.  Pohlman  held  that  as 
long  as  the  fetus  was  immature  and  attached  to  the  uterus  it  forms  a  part  of 
the  maternal  organism,  at  least  in  effect;  but  when  full  maturity  is  attained 
it  becomes  a  foreign  body  and  is  expressed  by  uterine  contractions.  The  causa- 
tion of  labor  is  a  very  complicated  question,  and  we  are  to-day  ignorant  of 
the  actual  determining  factor,  through  the  operation  of  which  a  uterus,  after 
remaining  comparatively  quiescent  for  thirty  odd  weeks,  suddenly  and  perhaps 
unexpectedly  takes  it  upon  itself  to  get  rid  of  a  burden  it  has  carried  so  long 
without  rebellion. 

It  is  probable  that  there  are  several  predisposing  causes,  and  that  the  real 
direct  or  exciting  cause  is  some  slight  circulatory  or  nervous  disturbance  brought 
on  by  overexertion,  an  overdose  of  cathartic,  a  misstep,  straining  at  stool  or 
micturition,  or  mental  excitement. 


V.  THE  STAGES  OF  LABOR. 

It  is  customary  to  divide  labor  into  three  periods  or  stages:  namely,  first, 
second,  and  third,  and  designated  respectively,  stage  of  dilatation,  of  expulsion, 
and  last  of  placental  delivery  and  uterine  contraction  and  retraction.  To 
these  we  add,  without  assigning  it  a  number,  another;  namely,  the  preparatory 
stage. 

The  preparatory  stage  of  labor  extends  from  subsidence  or  sinking  of  the 
uterus  until  true  labor  sets  in,  and  begins  about  two  weeks  before  true  labor 
in  primigravidce  and  ten  days  before  in  multigravidaj.  Its  phenomena  consist 
in  (i)  sinking  of  the  uterus,  the  so-called  "lightening";  (2)  gradual  shortening 
of  the  cervix  and  dilatation  of  the  internal  os,  and  (3)  false  or  spurious  labor 
pains. 

I.  In  the  sinking  of  the  uterus  the  organ  sinks  lower  in  the  pelvis,  the  fundus 
drops  forward,  and  the  head  either  engages  or  sinks  down  to  the  pelvic  floor. 
Deep  engagement  of  the  head  is  more  marked  and  more  constant  in  primi- 
gravidse  by  reason  of  the  tense  abdominal  muscles,  strong  uterine  muscles, 
and  greater  intraabdominal  pressure.  In  both  primigravidae  and  multigravidas 
we  often  observe  the  head  distending  and  pushing  down  into  the  pelvis  the 
thinned  anterior  wall  of  the  lower  segment,  with  resulting  posterior  displace- 
ment of  the  cervix,  so  that  the  os  looks  backward  and  upward.  This  is  the 
so-called  sacciform  dilatation  of  the  anterior  part  of  the  lower  uterine  segment 


THE  STAGES   OF  LABOR.  433 

(Fig.  790).  This  change  affords  great  relief  to  the  woman;  her  respiration 
is  less  embarrassed,  her  clothes  are  looser,  and  her  digestion  is  improved.  The 
irritability  of  the  bladder  and  rectum  becomes  more  marked;  mucus  pours 
from  the  vaginal  and  cervical  glands  and  is  generally  a  very  good  indication 
of  the  progress  of  the  dilatation  of  the  cervix. 

2.  The  gradual  shortening  of  the  cervix  and  dilatation  of  the  internal  os.  The 
cervix,  as  a  rule,  retains  its  entirety  until  the  thirty-sixth  or  thirty-eighth  week 
of  gestation;  up  to  this  time  the  cervical  canal  is  one  inch  long,  the  external 
and  the  internal  openings  are  closed,  the  supra- vaginal  and  infra- vaginal  por- 
tions are  present  very  much  as  in  the  non-pregnant  state.  The  greater  intra- 
uterine pressure  and  distention  of  the  lower  uterine  segment  in  primigravidae 
causes  a  gradual  expansion  and  unfolding  of  the  supra-vaginal  cervix  at  about 
the  thirty-sixth  week;  but  in  multigravidae,  because  of  the  previous  distention 
of  the  lower  uterine  segment,  pressure  is  not  so  readily  communicated  to  the 
margin  of  the  internal  os,  and  dilatation  here  does  not  commence  until  about 
the  thirty-eighth  or  thirty-ninth  week.  At  the  end  of  gestation  in  primigravidae 
the  internal  os  has  usually  expanded  and  disappeared  for  the  reception  of  the 
ovum;  this  is  much  less  often  the  case  in  multigravidae.  In  pathological  in- 
stances of  overdistention,  such  as  hydramnios  and  multiple  pregnancy,  the  un- 
folding and  complete  disappearance  of  the  internal  os  is  most  clearly  shown, 
and  is,  in  some  instances,  nearly  complete.    (See  the  Parturient  Canal,  page  400.) 

3.  The  false  or  spurious  labor  pains  are  the  normal  intermittent  uterine 
contractions  of  gestation  occurring  more  frequently  than  usual,  with  greater 
intensity  and  accompanied  by  pain.  They  are  often  caused  by  a  temporary 
indigestion  or  rectal  distention,  and  hence  are  often  relieved  by  a  laxative 
or  enema.  They  are  distinguished  from  true  uterine  pains  by  their  temporary 
character,  irregularity,  being  felt  generally  over  the  abdomen  instead  of  in  the 
lumbo-sacral  region  or  just  above  the  pubes;  by  not  progressing  in  frequency 
and  severity  and  in  not  causing  any  hardening  or  dilatation  of  the  os.  The 
most  definite  symptom  of  the  commencement  of  labor  is  the  presence  of  uterine 
contractions  or  pains,  recurring  at  intervals  which  gradua,lly  decrease  in  length, 
while  the  force  of  the  contractions  increases,  and  causing  a  gradual  thinning 
and  dilatation  of  the  cervix. 

I.  The  first  stage  of  labor,  or  stage  of  dilatation,  extends  from  the  onset  of 
true  labor  pains  to  the  complete  dilatation  or  dilatability  of  the  os.  The  dura- 
tion of  this  stage  is  variable;  it  may  be  as  short  as  two  hours  or  it  may  continue 
several  days.  The  length  is  influenced  by  the  age  of  the  patient  and  by  the 
number  of  children  she  has  borne,  it  being  longest  in  elderly  women,  especially 
primiparas.  The  average  duration  for  primiparse  is  often  stated  to  be  sixteen 
hours,  though  it  may  be  much  longer;  while  for  multiparae  an  average  of  nine 
hours  may  be  quoted.  The  phenomena  of  this  stage  are  (i)  true  uterine  con- 
tractions or  labor  pains;  (2)  a  muco-sanguineous  discharge;  (3)  the  mech- 
anism of  cervical  dilatation;  (4)  the  formation  of  the  caput  succedaneum. 

I.  The  true  labor  pains  cause  the  patient  to  assume  different  attitudes; 
she  is  restless,  often  walking  about  from  place  to  place  and  emitting  cries  on 
the  occurrence  of  a  "pain,"  very  different  in  character  from  those  of  the  later 
stages.  The  contractions  or  "pains,"  which  at  first  are  not  very  annoying, 
occur  about  every  half  hour,  and  are  accompanied  generally  by  pressure  sen- 
sations. At  first  the  pain  is  apt  to  be  felt  in  the  region  of  the  sacrum,  which 
is  the  common  location  for  pain  originating  from  any  cervical  trouble,  and 
it  may  radiate  to  the  lower  abdomen  or  down  the  legs.  Generally  the  first 
pains  come  on  in  the  early  part  of  the  night,  and  in  character  thev  closelv  re- 
28 


434 


PHYSIOLOGICAL  LABOR. 


semble  the  false  pains  which  are  often  felt  in  the  last  weeks  of  pregnancy.  The 
woman  is  frequently  more  impatient  of  the  pains  of  dilatation  than  she  is  of  the 
later  ones,  because  she  fails  to  see  that  any  progress  is  being  made,  although 
the  passage  of  the  head  over  the  exquisitely  sensitive  perineum  causes  the 
most  excruciating  agony  experienced  during  all  the  course  of  labor.  The 
patient  often  vomits  or  shivers  at  this  stage;  there  is  an  abundant  secretion 
of  urine;  the  cervix  grows  gradually  more  patulous  till  its  edges  become  con- 


FiG.  555. — Frozen  Section  after  Sudden  Death  from  Cerebral  Abscess,  during 
THE  First  Stage  of  Labor.  Age  of  patient  thirty-seven  years;  7-para;  fundus 
uteri  3  inches  above  the  umbihcus;  internal  os  dilated  to  admit  two  fingers.  The 
section  is  a  vertical  mesial  one  with  the  frozen  fetal  parts  of  the  opposite  side  placed 
in  exact  superposition.  Note  the  posture  of  the  fetus  and  moulding  of  the  head, 
the  latter  being  well  above  the  pelvic  floor;  also  the  lower  borders  of  the  peritoneum 
anteriorly  and  posteriorly;  the  beginning  formation  of  the  "bag  of  waters,"  ' 
the  contraction  ring;  and  the  distended  rectum. — {William  C.  Lusk's  case.) 


and 


tinuous  with  the  walls  of  the  vagina.  When  the  diameter  of  the  openmg  reaches 
about  three  inches,  the  descending  "bag  of  waters"  ruptures,  allowing  a  little 
of  the  liquid  to  escape,  while  the  remainder  is  kept  back  by  the  ball  valve-Hke 
action  of  the  head.  The  temperature  rises  slightly  and  the  pulse  of  the  patient 
increases  during  a  uterine  contraction,  but  the  fetal  heart-beat  is  slowed  at  the 
height  of  a  pain. 

2.  The    muco-sanguineous   discharge.     All   of   the    secretions,    both    vaginal 


THE  STAGES   OF  LABOR.  435 

and  cervical,  are  increased  with  the  progress  of  labor,  and  they  serve  as  a  lubri- 
cant to  the  passages.  As  the  lower  uterine  segment  and  the  cervix  expand 
the  lower  part  of  the  menibranes  is  separated  from  the  wall  of  the  uterus,  giving 
rise  to  a  slight  hemorrhage  which  streaks  the  mucous  discharge,  and  early 
in  labor  the  bloody  mucus  is  known  as  the  "  show." 

3.  The  mechanism  of  cervical  dilatation  (Figs.  556  to  564).  According  to  well- 
known  hydrostatic  laws,  the  pressure  of  the  uterine  walls  in  the  state  of  contrac- 
tion is  communicated  to  the  fluid  in  the  bag  of  waters  in  a  generally  uniform  man- 
ner, barring  the  variations  which  occur  at  different  levels,  and  which  are  due  to 
the  weight  of  the  liquid  (Fig.  565).  There  is  no  propulsion  till  the  cervix  begins 
to  be  dilated,  and  then  the  bag  of  waters  is  forced,  to  a  certain  degree,  out 
of  the  OS,  the  fetus  in  itself  not  being  acted  upon,  but  the  force  is  expended 
on  the  entire  ovum  (Fig.  566).  The  direction  of  the  force  is  in  the  central 
axis  of  the  os  and  in  a  line  perpendicular  to  its  plane.  The  uterus  acts  in 
two  ways:  (i)  when  it  contracts  its  internal  area  is  diminished,  and  the  result 
is  intrauterine  fluid  pressure  caused  by  the  force  exerted  on  the  fluid  within 
the  ovum;  (2)  after  rupture  of  the  membranes,  and  the  consequent  escape 
of  fluid,  there  occurs  direct  contact  between  the  fundus  and  the  breech,  and, 
indeed,  this  may  very  occasionally  occur  before  the  membranes  are  ruptured. 
The  abdominal  muscles  assist  the  uterus  in  both  these  forms  of  action;  they 
add  their  part  to  the  force  exerted  by  the  uterus  before  the  membranes  are 
ruptured  as  well  as  after  this  event  takes  place.  The  os  may  be  said  to  be 
dilated  normally  by  the  protruding  bag  of  waters;  this  being  the  case  when 
the  fluid  is  abundant  and  the  membranes  are  unruptured.  When  these  con- 
ditions are  present,  the  intrauterine  fluid  pressure  has  no  effect  on  the  fetus; 
this  can  be  inferred  from  the  law  in  hydrostatics  that  fluid  pressures,  whatever 
the  cause,  are  always  equal  and  opposite  in  all  directions;  hence  the  fetus  is 
not  affected  by  contractions  of  the  uterine  musculature.  Although  the  lower 
uterine  segment  makes  an  effort  at  contraction,  it  is  forced  open  at  the  os  by 
the  power  of  the  upper  strong  part.  It  is  well  known  that  the  lower  uterine 
segment  is  by  far  the  weakest  part  of  the  uterus,  and  so,  during  contraction, 
its  tendency  is  to  expand;  this  being  the  effect  of  the  intrauterine  fluid  pres- 
sure. That  part  of  the  area  of  the  uterus  which  is  opposite  the  vagina  is  not 
supported  by  the  intra-abdominal  pressure  nor  by  the  abdominal  muscles, 
both  of  which  factors  hold  sway  above.  In  this  way  not  only  is  the  centri- 
fugal force  increased,  but  the  centripetal  force  is  diminished.  Another 
feature  which  adds  to  the  weakness  of  this  part  of  the  organ  is  the  os — an 
opening  in  the  uterine  wall  much  weaker  than  the  Fallopian  tube  open- 
ings. So  that,  indeed,  the  very  first  effect  of  uterine  contractions  is 
seen  in  the  expansion  of  the  lower  uterine  segment.  While  the  internal 
OS  and  upper  cervix  and  supravaginal  portion  are  dilating,  the  bag  of 
waters  begins  to  bulge  through  the  os,  and  the  fluid  pressure  can  then  act 
directly  on  its  edges.  This  process  gradually  proceeds  till  the  internal  os 
disappears,  the  cervix  shortens  till  it  also  is  abolished,  and  then  the  mem- 
branes act  directly  on  the  external  os.  The  force  exerted  by  the  membranes 
is  directly  proportional  to  their  convexity.  This  can  be  explained  by  the 
law  in  physics  that  the  fluid  pressure  is  opposite  and  equal  in  all  points,  and 
is  exerted  at  right  angles  to  any  surface  against  which  it  acts.  Consequently 
the  rapidity  of  dilatation  will  correspond  with  the  degree  of  bulging  of  the 
membranes  through  the  os.  After  the  membranes  are  ruptured  these  laws  are 
applicable  to  the  force  exerted  by  the  head  in  causing  dilatation.  These  facts, 
together  with   that  of  the  successively  increasing  force  of  uterine  contractions, 


436 


PHYSIOLOGICAL  LABOR. 


Fig.  556.  —  Primiparous 
Cervix  at  the  Begin- 
ning OF  Uterine  Con- 
tractions. 


Fig.     557.  —  Primiparous 
Cervix  Early  in  Labor. 


Fig.  558. — Cervix  in  Mul- 
tipara AT  Beginning 
of  Uterine  Contrac- 
tions. 


Fig.     559.  —  MuLTiPARous 
Cervix  Early  in  Labor. 


Fig.  560.  —  Primiparous 
and  Multiparous  Cer- 
vix. Dilatation  for 
Two  OR  Three  Fin- 
gers. 


Fig.  561. — "False  Wa- 
ters." Fluid  between 
Chorion  and  Uterine 
Wall  above  and  be- 
tween Chorion  and 
Amnion   Below. 


Fig.  562. — Primiparous  or 
Multiparous  Cervix. 
Os  One-half  Dilated. 
Internal  Os  drawn  up 
into  Lower  Uterine 
Segment. 


Fig.  563.  —  Rupture  of 
THE  Membranes.  i, 
Usual  site;  2,  just  inside 
the  os;  3,  within  the 
uterus. 


Fig.  564. — Formation  of 
A  Second  Bag  of 
Waters. 


THE  STAGES  OF  LABOR. 


437 


explain  why  the  last  stages  of  dilatation  are  nearly  always  more  rapid  than 
the  first.  To  refer  back  to  what  was  called  the  normal  mechanism  of  the 
first  stage, — the  membranes  being  unruptured, — the  progress  of  the  first  stage 
of  labor  is  chiefly  due  to  the  first  form  of  uterine  force,  the  intrauterine  fluid 
pressure,  while  the  membranes  act  only  as  dilators.  The  second  form  has  not 
yet  been  called  into  play, — direct  pressure  of  the  walls  on  the  child, — neither 
is  the  voluntary  action  of  the  abdominal  muscles  often  present,  so  the  intra- 
uterine fluid  pressure  due  to  the  general  intra-abdominal  pressure  always 
exerted  by  the  tonicity  of  these  muscles  is  to  be  looked  upon  as  the  important 
factor  in  causing  the  progress  of  labor  at  this  stage. 

4.  Caput  succedaneum.     If  this   stage  is  prolonged,   a   scalp   tumor  forms 


J   I   I 


Fig.  565. — General  In- 
trauterine Pressure 
DURING  A  Uterine  Con- 
traction,  before  Rup- 

'  ture  of  the  mem- 
BRANES. The  X  and  — 
signs  indicate  the  results 
of  general  intrauterine 
pressure. 


A  — 


Fig.  566. — Further  Result 
OF  General  Intrauter- 
ine Pressure.  The  lower 
segment  is  weakened, 
thinned,  and  dilated. 
A,  A,  and  B  indicate  the 
directions  of  the  remain- 
ing pressures. 


Fig.  567. — Still  Further 
Result  of  the  General 
Intrauterine  Pressure. 
The  fetus  is  partially  ex- 
pelled from  the  cervix, 
and  the  uterus  in  conse- 
quence shortens  and  be- 
comes thicker  in  its  upper 
part.  A,  A,  Lateral  uter- 
ine pressure;  B,  direct 
pressure  of  the  thickened 
fundus  upon  the  fetal  axis. 


on  that  portion  of  the  head  least  subjected  to  pressure,  due  to  venous  conges- 
tion and  oedema.     (Compare  Part  IX.) 

2.  The  second  stage  of  labor,  or  stage  of  expulsion,  extends  from  the  com- 
plete dilatation  or  dilatability  of  the  os  to  the  complete  expulsion  of  the  fetus. 
The  duration  of  this  stage  varies  from  a  few  minutes  to  six  hours  or  more.  Its 
average  duration  in  primiparae  is  from  two  to  three  hours,  and  in  multiparas  from 
one  to  two  hours.  The  pheno.mena  of  this  stage  consist  in:  (i)  Characteristic 
uterine  contractions;  (2)  the  use  of  voluntary  forces;  (3)  the  descent  of  the 
presenting  part ;  (4)  the  dilatation  of  the  vagina;  (5)  the  dilatation  of  the  vulva; 
(6)  the  expulsion  of  the  fetus. 

I  and  2.  Uterine  contractions  and  the  use  of  voluntary  forces.  The  nature  of 
the  contractions  is  entirely  changed;  they  are  far  more  severe  than  in  the  first 
stage,  and  are  bearing-down  in  character;  the  voluntary  forces  are  now  utilized; 


438 


PHYSIOLOGICAL  LABOR. 


the  patient  makes  use  of  the  diaphragm  and  the  abdominal  muscles;  she  braces 
herself  for  every  paroxysm  and  holds  tightly  to  whatever  support  may  be  at 
hand.  The  cry  differs  also  from  the  earher  one,  the  patient  often  taking  a  quick 
inspiration  in  the  midst  of  a  pain  in  order  to  be  able  to  resume  the  expulsive 
effort,  this  being  accompanied  by  a  characteristic  grunt  or  the  whole  ended  by  a 
moan.  The  pams  are  now  efficient,  and  as  the  fetus  is  driven  out  through  the 
dilated  cervix  the  vagina  relaxes  to  receive  it.     When  the  perineum  is  reached, 


Fig.  568. — Central  Separation  of  the 
Placenta  from  the  Uterine  Wall, 
WITH  the  Formation  of  a  Retropla- 
cental  Blood-mass.  (Schultze's  mech- 
anism.) 


Fig.  569. — Descent  of  the  Placenta 
Doubled  upon  Itself,  with  the  Center 
OF  THE  Fetal  Surface  Presenting. 
(Schultze's  mechanism..) 


Fig.  570. — Descent  of  the  Placenta  with 
THE  Lower  Border  First,  through  the 
Cervix  and  Vagina.  (Duncan's  mech- 
anism.) 


Fig.  571. — Complete  Separation  of  the 
Placenta.  The  placenta  is  expelled  flat 
with  the  lower  margin  first  presenting. 
(Duncan's   mechanism.) 


its  firm  but  elastic  structures  bulge  with  every  uterine  contraction  and  recede 
with  its  subsidence.  The  pelvic  floor  directs  the  presenting  part  upward  and 
forward  toward  the  orifice  of  the  vulva.  Mucus  lubricates  both  the  passages 
and  fetus,  and  thus  the  vagina  more  easily  allows  the  onward  movement  of  the 
fetus.  Between  the  pains  the  soft  parts  press  back  the  fetus  till  the  presenting 
part  is  so  firmly  fastened  under  the  symphysis  pubis  that  this  cannot  recur. 
Finally  the  vulva  gapes ;  the  presenting  part  is   seen ;  the  anus  relaxes  and  the 


THE  STAGES   OF  LABOR.  439 

rectal  wall  appears;  there  is  an  uncontrollable  desire  to  micturate  and  defecate, 
due  to  pressure  on  bladder  and  rectum;  there  comes  the  crowning  effort,  and  the 
head  passes  through  the  external  opening  (Fig.  590).  The  fundus  uteri  now  quickly 
subsides  and  the  uterine  muscle  is  in  close  contact  with  the  parts  of  the  fetus 
still  contained  within  it.  At  this  stage  there  generally  occurs  a  slight  pause, 
varying  in  duration.  There  is  sometimes  a  cry  at  the  expulsion  of  the 
head  and  sometimes  the  patient  makes  no  sound;  when  present,  this  has  been 
known  as  the  physiological  cry. 

3.  The  third  stage  of  labor,  or  stage  of  placental  delivery  and  uterine  con- 
traction and  retraction,  extends  from  complete  expulsion  of  the  fetus  to  com- 
plete expulsion  of  the  placenta  and  membranes.  The  average  duration  of  this 
stage  is,  when  spontaneously  completed,  about  one  hour.  Immediately  after 
birth  the  patient  feels  calm  and  comfortable.  Now  and  then  there  is  a  feeling 
of  faintness  caused  by  the  sudden  evacuation  of  the  uterus.  The  phenomena 
of  the  third  stage  are:  (i)  characteristic  uterine  contractions;  (2)  the  control 
of  hemorrhage;  (3)  the  separation  of  the  placenta;  (4)  the  expulsion  of  the 
placenta;  (5)  the  physiological  chill. 

1.  Uterine  contractions.  After  the  completion  of  the  second  stage  the  uterus 
may  be  palpated  in  the  hypogastrium,  and  should  resemble  a  firm,  round,  ball- 
shaped  body,  and  more  or  less  tonic  as  well  as  rhythmic  contractions  should 
be  present,  although  the  latter  are  not  necessarily  felt  by  the  woman  as  "  pains." 
The  hardness  of  the  uterus  varies  at  this  time  and  after  the  expulsion  of  the 
placenta,  but  the  risk  of  hemorrhage  is  not  necessarily  great  unless  there  is 
much  relaxation  between  the  intermittent  contractions,  or  sudden  gushes  of 
blood  occur  during  or  between  the  contractions. 

2.  The  control  of  hemorrhage  at  this  time  is  primarily  due  to  the  constriction 
of  the  vessels  by  the  firm  and  tonic  uterine  contractions,  and  secondarily  to 
coagulation  of  the  blood  in  the  mouths  of  the  vessels. 

3.  Placental  detachment.  At  or  just  before  the  expulsion  of  the  fetus,  the 
placenta  is  partially  detached  from  the  uterus.  Shrinkage  of  the  placental 
site  and  the  forcing  downward  of  the  whole  placental  mass  by  uterine  con- 
tractions account  for  this  separation.  The  usual  and  I  believe  normal  manner 
of  placental  delivery  is  for  it  to  be  folded  on  itself  by  the  contracting  uterus, 
so  that  the  long  axis  of  the  placenta  corresponds  to  the  long  axis  of  the  uterus, 
and  the  margin  that  presents  at  the  cervix,  vagina,  and  vulva  is  the  lower 
margin,  showing  perhaps  a  little  of  its  fetal  surface  (Duncan's  method)  (Figs. 
57O1  571)-  Occasionally,  especially  when  traction  has  been  made  upon  the  cord, 
the  center  of  the  fetal  surface  with  the  attached  cord  presents  first,  like  an 
inverted  umbrella  (Schultze's  method)  (Figs.  568,  569).  It  makes  very  little 
difference,  from  a  practical  standpoint,  how  the  placenta  is  bom. 

4.  Placental  expulsion  occasionally  occurs  with  or  just  after  the  birth  of 
the  fetus;  usually,  however,  in  purely  spontaneous  placental  delivery,  an  hour 
or  even  more  intervenes  between  the  fetal  and  the  placental  delivery.  During 
this  time  the  uterus  should  be  moderately  hard  as  the  result  of  tonic  contraction, 
and  intermittent  or  rhythmic  contractions,  though  not  strongly  marked,  should 
be  present,  thus  causing  the  uterus  to  vary  in  hardness.  The  intermittent 
contractions  after  a  short  time  become  stronger,  nearer  together,  and  finally 
are  felt  as  "  pains  "  by  the  patient,  and  a  little  blood  is  expelled  by  them  from 
the  vagina.  In  spontaneous  expulsion  these  contractions  finally  complete  pla- 
cental separation  and  force  the  placenta  down  so  that  it  lies  partly  in  the 
flaccid,  relaxed  cervix  and  partly  in  the  vagina.  In  the  absence  of  inter- 
ference its  expulsion  from  the  vulva  is  accomplished  by  the  voluntary  forces, 
aided  by  the  contractions  of  the  uterus  and  vagina. 


440  PHYSIOLOGICAL  LABOR. 

■J 
5.  Physiological  chill.  Not  uncommonly  some  slight  shivering,  in  some  cases, 
— about  15  percent., — even  passing  into  a  decided  chill,  takes  place  shortly  after 
the  placental  delivery.  It  is  more  often  observed  after  rapid  deliveries,  and 
may  continue  from  a  few  minutes  to  a  quarter  of  an  hour,  and  is  unattended 
by  any  alterations  in  the  pulse  or  temperature.  Its  best  explanation  is  that 
the  organism,  or  rather  the  abdomen,  loses  a  large  mass  to  which  it  had  been 
previously  accustomed,  the  result  being  that  the  internal  viscera  are  no  longer 
compressed,  and  we  have  a  rapid  rush  of  blood  from  the  exterior  to  fill  the 
space  left  in  these  organs.  Consequently  a  more  or  less  severe  chill  results, 
which  is  entirely  physiological  and  is  not  a  signal  of  danger. 


VI.  THE  MECHANISM  OF  LABOR. 

Definition. — The  mechanism  of  labor  is  the  manner  in  which  the  fetus  passes 
through  the  parturient  canal;  and  it  has  to  deal  with  the  hard  and  the  soft 
parts  which  compose  the  latter  and  with  the  fetus  and  the  expelling  forces. 
It  treats  of  the  movements  of  the  fetus  through  and  out  of  the  parturient  canal, 
and  the  causation  and  character  of  these  movements. 

Importance. — Familiarity  with  the  three  factors  of  labor — namely,  the 
passages,  the  passenger,  and  the  forces — is  essential  in  order  to  appreciate 
the  combination  of  movements  known  as  the  mechanism  of  labor  by  which 
nature  guides  the  fetus  from  the  uterine  cavity  through  the  pelvis  into  the 
external  world.  With  equal  success  might  we  hope  to  appreciate  and  treat 
certain  cardiac  diseases  without  an  understanding  of  the  anatomy  and  physi- 
ology of  the  heart,  as  to  attempt  the  management  of  labor  cases  without  a  clear 
knowledge  of  the  mechanism  of  parturition.  It  is  true  that  one  ignorant  of 
the  mechanism  of  labor  may  successfully  care  for  cases  of  normal  confinement ; 
it  is  equally  true,  in  other  instances,  that  this  want  of  knowledge  results  in 
disaster  to  mother  and  fetus. 

But  one  mechanism,  of  labor.  From  a  mechanical  standpoint  all  labors  are 
subject  to  the  same  physical  laws  and  follow  these  laws,  provided  only  that 
expulsion  occurs,  spontaneously  and  at  term,  of  a  normal-sized  fetus,  and 
through  a  normal  pelvis:  in  premature  labors  and  in  cases  of  monstrosities 
and  deformed  pelves  many  departures  from  the  usual  mechanism  occur.  It 
may  be  stated,  then,  that  there  is  but  one  mechanism  of  labor  for  all.  The 
mechanism  of  the  first  vertex  position  (L.  O.  A.)  may  be  looked  upon  as  the 
standard;  and  the  mechanism  of  the  other  three  positions  of  the  vertex,  and 
the  several  positions  of  the  breech,  face,  and  brow,  as  following  the  same  general 
standard. 

Six  Stages. — Six  clearly  defined  stages  of  mechanism  in  all  presentations 
and  positions,  with  the  exception  of  shoulder  presentation,  can  usually  be 
demonstrated.  These  stages  are:  (i)  Moulding;  (2)  engagement  and  descent; 
(3)  rotation  of  the  first  part  of  the  fetal  ellipse;  (4)  expulsion  of  the  first  part 
of  the  fetal  ellipse;  (5)  rotation  of  the  second  part  of  the  fetal  ellipse;  (6)  expul- 
sion of  the  second  part  of  the  fetal  ellipse. 

I.  Moulding. — In  the  first  stage  the  fetus,  pressed  upon  and  influenced 
by  the  general  intrauterine  pressure,  and  perhaps  also  to  a  slight  extent  by 
the  voluntary  efforts  of  the  mother,  tends  to  accommodate,  to  mould  the  shape 
of  its  presenting  part  to  suit  the  canal  through  which  it  has  to  pass.  This 
moulding  in  vertex  presentation  is  accomplished  by  overriding  of  the  bones 


THE   MECHANISM   OF  LABOR. 


441 


of  the  vault  of  the  skull  and  by  actual  change  of  the  shape  of  the  brain;  in  brow 
presentations  the  same  causes  operate;  in  face  presentations,  the  bones  of 
the  face  proper  change  very  little,  although  a  characteristic  moulding  of  the 
frontal,  parietal,  and  occipital  bones  occurs,  and  swelling  and  oedema  of  the 
facial  tissue  assists  in  the  acquired  general  shape  of  the  head;  in  breech  pres- 
entation moulding  is  entirely  due  to  compression  of  the  soft  tissues. 

II.  Engagement  and  Descent. — Engagement  of  the  head  in  the  pelvis  in  vertex 
presentations,  especially  in  primigravid^-e,  often  occurs  before  labor  sets  in.      En- 


FiG.  573. — The  Mechanism  of  Labor.  The  Head  in  the  Left  Occipito-anterior 
Position  on  the  Pelvic  Floor  before  Anterior  Rotation  and  Dilatation  of 
THE  Vulval  Orifice. 


gagemenl  and  descent  occur  more  readily  and  promptly  in  anterior  positions  of 
the  vertex  and  with  moderate-sized  fetuses.  Dela5^ed  engagement  and  descent  we 
observe  in  posterior  positions  of  the  vertex ;  in  primary  or  secondary  inertia  of  the 
uterus;  in  excessive  uterine  obliquity  and  torsion;  in  brow  presentations,  since  a 
greater  circumference  presents;  in  face  and  breech  presentations  because  these 
parts  are  irregular,  are  poor  dilators,  and  are  subject  to  oedematous  swelling. 
Naturally  engagement  and  descent  in  any  presentation  or  position  are  favored  by 
undersized  fetuses  and  roomy  pelvic  inlets. 

III.  Rotation  of  the  First  Part  of  the  Fetal  Ellipse. — All  explanations  cf  in- 


442 


PHYSIOLOGICAL   LABOR. 


ternal  rotation  apart  from  the  fetus  may  be  classed  as  (i)  uterine  and  (2)  pelvic. 
The  uterine  theory  attributes  a  rotation  force  to  the  uterus  itself.  The  pelvic 
explanation  takes  into  account  the  shape  of  the  pelvis — as  determined  by  the 
ischial  spines  and  planes  and  varying  lengths  of  the  pelvic  diameters — and  the 
shape,  resistance,  and  actions  of  the  structures  going  to  make  up  the  perineal 
floor.  The  anatomical  investigations  of  J.  Veit  *  and  H.  Varnier  f  deny  to  the 
shape  of  the  pelvis — namely,  the  varying  lengths  of  the  various  planes — and  even 
to  the  bones  of  the  pelvic  outlet  any  influence  on  the  internal  rotation  of  the 
head.  The  latter  explains  the  rotation  of  the  head  as  due  exclusively  to  the 
arrangement  of  the  muscles  of  the  pelvic  floor  and  the  perineum. 


Fig.  573. — The  Mechanism  of  Labor.  The  Head  in  the  Left  Occipito-anterior 
Position  on  the  Pelvic  Floor.  A  caput  succedaneum  has  formed,  anterior  rotation 
has  just  begun,  and  partial  dilatation  of  the  parturient  outlet  has  taken  place. — 
(Studd-i ford's  frozen  section  at  the  Emergency  Hospital.) 


Desiring  to  test  for  myself  experimentally  the  part  the  pelvic  floor  plays  on  anterior 
rotation  of  the  presenting  part,  I  undertook  the  following  experiments:  I  screwed  a  swivel 
into  the  head  of  a  fetal  cadaver  half  an  inch  behind  the  small  fontanelle,  attaching  a  yard 
of  cord  to  the  ring  of  the  swivel.  I  repeatedly  dragged  the  head  through  the  pelvis  of 
a  woman  dead  after  recent  delivery.  The  occiput  invariably  rotated  to  the  front,  even 
when  the  head  entered  the  pelvis  in  the  posterior  positions,  so  long  as  the  pelvic  floor  re- 
tained its  integrity.  When  the  tonicity  of  the  floor  became  impaired  by  overstretching, 
the  head  traversed  the  pelvis  in  very  nearly  the  same  position  at  it  had  entered.  J  In 
making  use  of  the  term  complete  rotation  of  either  head  or  shoulders  in  these  observations, 
it  was  not  meant  that  mathematically  complete  rotation  resulted,  but  only  such  as  pal- 
pation or  inspection  determined,  unaided  by  more  exact  means  of  measurement.  Leish- 
man's  researches  with  a  cord  stretched  from  symphysis  to  coccyx  showed  that  exact  co- 
incidence of  the  sagittal  suture  and  the  antero-posterior  diameter  of  the  pelvic  outlet 
failed  in  many  instances.     The  well-known  experiments  of  Paul  Dubois  consisted  in  push- 

*  "Die  Anatomic  des  Beckens  im  Hinblick  auf  den  Mech.  d.  Geb.,"  1887. 
t  "Du  Detroit  Inferieur  musculaire  du  Basin  obstetrical,"  Paris,  1888. 
X  Edgar:  "The  Mechanism  of  Labor,"  loc.  cit. 


THE   MECHANISM   OF  LABOR. 


443 


ing  fetal  cadavers  of  various  sizes  through  the  birth  canal  of  a  puerpera  recently  dead. 
He  found  that  the  occiput  turned  forward,  provided  the  pelvic  floor  was  not  injured  by 
rupture  or  overstretching.  Repetition  of  his  experiments  overstretched  the  floor,  and 
then  rotation  failed. 

Rotation  was  complete  and  readily  accomplished  in  the  first  of  my  experiments;  then, 
as  the  muscles  and  tissues  became  more  and  more  stretched  and  relaxed  as  the  result  of 
repeated  pressure  upon  them,  I  found  rotation  first  incomplete  and  finally  failing  to  occur 
altogether.  Given  the  normal  attitude  of  the  fetus  (extreme  flexion  of  the  head)  and 
good  expulsive  powers,  and  the  most  important  remaining  condition  for  forward  rotation 
and  a  normal  mechanism  is  a  firm  pelvic  floor. 


Fig.    574 — The    Mechanism    of    Labor.     The   Vertex    is    Dilating    the    Parturient 
Outlet  after  Anterior'  Rotation  of  the  Occiput — "Crowning." 


A  clear  mental  picture  of  the  shape  of  the  fetal  ellipse  and  of  the  parturient 
canal  is  absolutely  essential  to  the  further  understanding  of  the  mechanism 
of  parturition.  One  should  always  recollect:  (i)  The  fetal  ellipse  is  made 
up  of  two  parts,  a  bulkier  but  more  compressible  body,  and  a  relatively  smaller 
but  less  compressible  head;  these  parts  are  readily  movable  in  their  relation 
to  each  other  so  as  to  produce  degrees  of  flexion  and  extension  and  of  torsion 
and  rotation  (Fig.  544).  (2)  The  antero-posterior  diameters  of  the  head  are 
the  largest  diameters  (Fig.  545)-  (3)  While  it  is  true  that  the  greatest  diameter 
of  the  non-compressed  fetal  bod}?-  is  the  antero-posterior  one  at  the  level  of 
the  umbilicus,  still  the  greatest  diameter  of  the  shoulders  is  the  bisacromial, 
4f  inches  (12  cm.)  (Fig.  547);  and  at  the  breech,  the  bitrochanteric,  3+  inches 


444 


PHYSIOLOGICAL  LABOR. 


(g  cm.)  (Fig.  550).  (4)  The  most  dependent  portion  in  a  vertex  presentation 
is  the  occiput;  in  a  face  presentation,  the  chin;  in  a  brow  presentation,  the 
brow;  in  a  breech  presentation,  the  buttock  which  lies  in  the  anterior  segment 
of  the  pelvic  cavity;,  and  of  two  shoulders,  the  one  in  the  anterior  pelvic  seg- 
ment. (5)  The  greatest  resistance  of  the  pelvic  floor  is  found  in  the  posterior 
segment;  the  levator  ani  muscle  with  other  muscles  and  tissues  of  the  pelvic 
floor  enter  into  the  formation  of  a  scoop-like  body  with  the  greatest  resistance 
behind  a  line  joining  the  spines  of  the  ischii ;  the  tendency  and  function  of  which 
by  resistance  and  contraction  are  to  guide  and  direct  whatever  comes  in  contact 


Fig.   5  75. — The  Mechanism   of   Labor.     Extension  of  the  Head  through  the    Par- 
turient Outlet. 


with  it  anteriorly  toward  and  into  the  vulval  slit,  the  weakest  and  least  resistant 
portion  of  the  pelvic  floor.  (6)  The  parturient  canal  possesses  an  irregular, 
corkscrew-like  shape,  (a)  The  fetal  ellipse  rests  with  its  greatest  (antero- 
posterior) diameter  in  the  greatest  (transverse)  diameter  of  the  uterus.  Torsion 
of  the  uterus  swings  the  left  side  of  the  latter  forward  so  that  the  fetal  back 
points  midway  between  the  left  and  front  (Fig.  551).  (b)  The  roomiest  diam- 
eter of  the  parturient  pelvic  inlet  is  the  oblique  (Fig.  552);  into  this  the  pre- 
senting part  enters,  (c)  The  roomiest  diameter  of  the  parturient  pelvic  cavity 
is  still  the  oblique;  through  this  the  presenting  part  travels,     (d)  The  roomiest 


THE  MECHANISM   OF  LABOR. 


445 


diameter  of  the  bony  and  parturient  outlet  is  the  antero-posterior  diameter 
(Fig.  515);  this,  the  long  diameter  of  the  presenting  part  seeks,  assisted  by 
the  greater  resistance  of  the  posterior  segment  of  the  pelvic  floor  and  the  shape 
of  the  entire  segment.  (7)  From  the  foregoing  it  follows:  (a)  that  the 
longest  horizontal  diameter  of  the  uterus  is  the  transverse  diameter,  ren- 
dered oblique  in  its  relation  to  the  pelvic  inlet  by  the  torsion  of  the 
uterus  on  its  vertical  axis;  (b)  the  long  diameter  of  the  parturient  pelvic 
outlet    does   not   correspond  with   that   of   the    inlet,  hence  a  torsion,  a  rota- 


/ 


\    N 


Fig.  576. — The  Mechanism  of  Labor.  Internal  Rotation 
External  Rotation  of  the  Head,  or  ''Restitution." 
permits  the  birth  of  the  anterior  shoulder  first. 


OF  the  Shoulders  and 
The   unsupported   head 


tion  of  the  portion  of  the  fetal  ellipse  passing  from  one  to  the  other  in 
order  to  obey  the  law  of  physics  and  travel  in  the  direction  of  least  re- 
sistance occurs  ;  {c)  whatever  portion  of  the  presenting  portion  of  the  fetal 
ellipse  first  strikes  the  pelvic  floor,  whether  it  encounters  this  structure  in  front 
of  or  behind  a  median  transverse  diameter,  will  be  directed  forward  under  the 
symphysis  pubis  and  into  the  vulval  slit;  {d)  it  is  undoubtedly  the  fact  that 
it  is  not  one  factor  alone,  but  several,  that  determine  this  rotation.  Accommo- 
dation, adaptation,  the  great  principle  that  runs  through  all  the  mechanism 


446  PHYSIOLOGICAL  LABOR. 

of  labor,  whereby  the  long  diameter  of  the  presenting  part  adapts  itself  to 
the  long  diameter  of  that  part  of  the  pelvis  in  which  it  may  find  itself;  the 
corkscrew-like  arrangement  of  the  pelvis;  the  lessened  resistance  caused  by 
the  urethral  and  vaginal  orifices  in  front ;  the  greater  resistance  of  the  thicker 
and  heavier  tissues  in  the  posterior  half  of  the  pelvis;  the  inclination  of  the 
pelvis;  the  shape  of  the  child's  head;  the  inclination  of  the  uterus  causing 
the  anterior  part  of  the  presenting  portion  to  reach  the  pelvic  floor  first — all 
play  their  part  in  the  causation  of  anterior  rotation. 

Deep  Transverse  Position. — Not  uncommonly  in  elderly  multiparas  with  lax 
soft  parts  one  observes  a  deep  transverse  position  of  the  sagittal  suture  or 
bitrochanteric  diameter;  namely,  the  head  or  breech  advances  through  the 
lower  part  of  the  pelvis,  and  even  up  to  the  orifice  of  the  vulva,  in  a  transverse 
or  oblique  position,  and  internal  rotation  occurs  only  at  the  very  last  moment 
in  the  vulval  orifice.  This  possibility  must  ever  be  kept  in  mind  in  medium 
and  low  forceps  operations  upon  the  head  in  vertex,  face,  and  brow  presenta- 
tions; for  the  lateral  pelvic  walls  are  3^  inches  (9  cm.)  deep,  and  the  distance 
from  shoulders  to  occiput  in  vertex  presentations,  from  shoulders  to  chin  in 
face,  and  to  forehead  in  brow,  does  not  exceed  three  inches,  and  so  further 
descent  in  transverse  positions  without  rotation  and  escape  of  the  presenting 
part  would  draw  the  chest  into  the  pelvis  with  the  head,  and  the  dorso-sternal 
diameter,  3!  inches  (12  cm.),  added  to  the  presenting  head  diameter,  would 
result  in  impaction,  and  traction  with  the  forceps  would  greatly  endanger 
the  life  of  the  fetus  and  the  soft  parts  of  the  mother. 

rV.  Expulsion  of  the  First  Part  of  the  Fetal  Ellipse.  (See  Pathological 
Labor.) — This  is  the  head  in  cephalic  presentations  and  the  trunk  in  breech 
presentations.  The  manner  of  expulsion  of  the  head  will  depend  upon  the  pre- 
sentation and  position.  In  occipito-anterior  positions  the  head  is  expelled  by  a 
movement  of  extension  in  front  of  the  pubis;  in  permanent  occipito-posterior 
positions,  by  a  movement  of  extension  over  the  edge  of  the  perineum;  in  mento- 
anterior positions  of  face  presentation,  the  head  flexes  in  front  of  the  pubis;  in 
permanent  mento-posterior  positions  impaction  occurs  and  no  expulsion  results. 
In  brow  presentations  the  same  general  mechanism  as  in  occipital  presentations 
obtains.  In  breech  presentations  the  sacro-perineal  curve  and  the  drawing  for- 
ward of  the  presenting  part  by  the  levator  ani  muscle  cause  a  lateral  flexion  of 
the  trunk  during  its  expulsion  (compare  Fig.  138). 

V.  Rotation  of  the  Second  Part  of  the  Fetal  Ellipse. — This  occurs  (i)  in  the 
trunk  in  cephalic  presentations,  and  (2)  in  the  head  in  breech  presentations. 

I.  The  internal  rotation  of  the  trunk  in  cephalic  presentations,  vertex,  face, 
and  brow,  naturally  causes  an  external  rotation  of  the  expelled  head.  Internal 
rotation  of  the  head  in  breech  presentation  does  not  so  constantly  cause  external 
rotation  of  the  trunk  by  reason  of  the  greater  weight  and  bulk  of  the  latter. 
In  cephalic  presentation — namely,  vertex,  face,  and  brow — when  the  trunk  is  the 
second  part  to  be  expelled,  the  shoulders,  we  have  every  reason  to  believe,  enter 
the  pelvic  inlet  in  the  oblique  diameter  opposite  to  the  one  in  which  the  head 
entered ;  or,  if  the  head  entered  in  a  transverse  diameter,  it  is  possible,  in  a  roomy 
pelvis  and  with  a  child  that  is  not  too  large,  for  the  shoulders  to  enter  in  the 
opposite  diameter  or  in  the  antero-posterior  diameter  of  the  inlet.  At  all 
events,  we  usually  find  the  shoulders  first  in  an  oblique  diameter,  and  the  anterior 
portion  of  the  presenting  part,  because  of  the  direction  of  the  axis  of  the  superior 
strait,  is  lower  than  is  the  posterior;  consequently  it  is  this  part  that  first  reaches, 
and  is  influenced  by  the  resistance  at,  the  floor  of  the  pelvis  and  is  deflected 
anteriorly  to  the  pubic  arch.     If  both  shoulders  came  to  the  pelvic  floor  at  one 


THE  MECHANISM   OF  LABOR.  447 

and  the  same  time,  we  have  every  reason  to  beheve  that  they  would  both  be 
equally  influenced  by  the  factors  which  cause  anterior  rotation,  and  consequently 
the  bisacromial  diameter  would  remain  in  the  same  diameter  in  which  it  entered 
the  pelvic  inlet.  Observation  has  taught  me  that  while  complete  anterior 
rotation  of  the  head  is  the  rule,  yet  complete  rotation  of  the  shoulders  is  not 
by  any  means  so  constant  as  is  that  of  the  head.  I  made  observations  *  upon 
sixty-seven  primiparae  and  seventy  multiparas  as  regards  the  internal  rotation 
of  the  bisacromial  diameter,  and  found  that  complete  rotation  occurred  once 
in  1.3  cases  in  primiparae,  and  once  in  1.2  cases  m  multiparas.  It  will  be  seen 
from  the  above  that  complete  rotation  occurs  with  about  equal  frequency 
in  primiparae  and  multiparas.  Even  before  the  shoulders  begin  to  rotate  inter- 
nally we  see  an  unwinding,  as  it  were,  of  the  muscles  of  the  neck  that  have 
been  twisted  in  the  internal  rotation  of  the  fetal  head,  and  as  a  consequence 
the  head  makes  a  partial  movement  of  external  rotation,  and  this  first  partial 
movement  of  rotation  is  termed  "restitution."  When  the  shoulders  rotate 
within  the  pelvis,  there  must,  in  consequence,  be  a  decided  rotation  on  the 
part  of  the  head  which  is  already  delivered,  and  this  further  and  more  marked 
rotation  of  the  head  is  termed  external  rotation  of  the  head,  whereby  in  vertex 
L.  O.  A.  position  the  face  of  the  child  looks  almost  directly  to  the  inner  surface 
of  the  right  thigh  of  its  mother. 

2.  Head  rotation  in  breech  cases.  In  breech  presentations  when  the  head  is 
the  second  part  to  be  expelled,  the  long  diameter  of  the  head  enters  the  pelvis  in 
the  opposite  diameter  to  that  in  which  the  bitrochanteric  of  the  breech  engaged. 
Provided  the  head  continues  flexed  upon  the  sternum,  when  the  pelvic  floor 
is  reached,  rotation  of  the  occiput  to  the  pubis  and  of  the  face  to  the  hollow  of 
the  sacrum  occurs,  in  all  but  about  1.5  per  cent,  of  cases,  no  matter  what  the 
original  direction  of  the  occiput  at  the  inlet.  What  is  the  explanation  of 
this  rotation?  I  believe  it  is  to  be  found  at  the  occipital  end  of  the  head, 
which  is  the  most  prominent  and  consequently  the  most  positively  influenced 
by  the  pelvic  floor.  A  glance  at  a  cast  of  a  fetus  in  its  normal  attitude  will 
demonstrate  the  prominence  of  the  occiput  (Fig.  544).  If  the  forehead  were 
most  in  evidence,  then  the  opposite  rotation  would  occur. 

VI.  Expulsion  of  the  Second  Part  of  the  Fetal  Ellipse. — This  is  the  delivery 
(i)  of  the  trunk  in  cephalic  presentations,  and  (2)  of  the  head  in  breech  presen- 
tations. 

I.  First,  as  to  the  delivery  of  the  trunk  in  trunk-last  cases,  R.  Lefour  be- 
lieves the  posterior  shoulder,  as  a  rule,  is  born  first.  Auvard  found  that  in 
29  cases  the  posterior  shoulder  came  first  in  16  and  the  anterior  in  9  cases. 
He  recommends  in  all  cases  support  of  the  head  in  order  to  prevent  its  own 
weight  interfering  with  the  natural  progress  of  the  expulsion  of  the  body.  Leonet 
asserts  that  the  anterior  shoulder  first  disengages  in  90  out  of  100  cases  if  the 
fetal  head  be  not  supported;  that  the  posterior  shoulder  first  emerges  in  90 
out  of  100  cases  if  the  head  be  supported.  He  states  that  the  danger  to  the 
perineum  first  begins  upon  the  disengagement  of  the  posterior  shoulder.  Re- 
garding shoulder  delivery,  I  made  observations  on  69  primiparae  and  68  mul- 
tiparas, and  found  that  the  posterior  shoulder  was  born  three  times  as  often 
as  the  anterior  in  primiparae  and  two  and  a  half  times  as  often  in  multiparae. 
In  almost  every  one  of  the  above  cases,  however,  the  head  upon  delivery  was 
lightly  supported  by  the  hand;  this  support  results  in  favoring  the  birth  of 
the  posterior  shoulder  first.  The  posture  of  the  woman  does  not  appear  to 
affect  the  mechanism  of  shoulder  delivery,  as  my  observations  upon  15  cases 
*  "The  Mechanism  of  Labor."  loc.  cit. 


448 


PHYSIOLOGICAL  LABOR. 


of  spontaneous  delivery  in  primiparae  and  28  in  multiparas  in  dorsal  and  lateral 
postures  seemed  to  prove. 

2.   Head  expulsion  in  head-last  cases.      (See  page  531.) 


VII.  THE  DURATION  OF  NORMAL  LABOR. 

The  duration  of  the  several  stages,  as  well  as  the  total  duration,  varies  within 
wide  limits  in  different  individuals.  Labor  is  generally  one-third  shorter  in  multi- 
parse  than  in  primiparae,  on  account  of  the  soft  parts  offering  less  resistance  after 
previous  labors.  The  duration  of  the  spontaneous  first  stage  may  be  approxi- 
mately stated  as  ten  to  fourteen  hours  in  primiparae,  and  six  to  ten  hours  in  mul- 
tipara; of  the  second  stage,  two  hours  for  the  former  and  one  hour  for  the  latter. 
The  duration  of  the  third  stage  varies  from  a  few  minutes  to  two  hours;  the 
average  being  about  half  an  hour.  It  is  rarely  spontaneously  completed  in  this 
country.  An  obstetric  tradition  holds  that  labor  is  especially  prolonged  in  elderly 
primiparae  (thirty  to  forty  years).  The  statistics  of  Courtade  of  the  Tarnier  Clinic 
(1900)  and  the  author's  show  that  labor  in  elderly  primiparse  is  but  slightly 
longer  on  the  average  than  in  primiparae  in  general.     (See  Maternal  Dystocia.) 

The  following  table  gives  the  average  duration  of  spontaneous  labor  in 
544  primiparae  and  910  multiparas,  and  the  average  duration  in  47  elderly  primi- 
parae   from    among   the   lower  and  laboring  classes  of  New  York. 


Of  the  primiparae,  the  longest  duration  of  the  first  stage  was  fifty-four  hours; 
the  shortest,  forty-five  minutes.  Of  the  544  labors,  the  second  and  third  stages 
took  place  practically  together  in  two  cases.  Of  the  multiparas,  the  longest 
duration  of  the  first  stage  was  forty-four  hours;  the  shortest,  thirty  minutes. 
The  second  and  third  stages  took  place  practically  together  in  three  cases. 
Of  the  elderly  primiparse,  the  longest  duration  of  the  first  stage  was  fifty-three 
hours  twenty  minutes;  the  shortest,  fifty  minutes.  The  longest  total  duration 
of  labor  was  fifty-three  hours  thirty-five  minutes;  the  shortest,  two  hours 
ten  minutes.  Of  the  47  cases,  in  no  instance  did  the  placenta  follow  imme- 
diately the  birth  of  the  child  (see  Maternal  Dystocia). 


VIII.  LIVE  BIRTH. 

By  live  birth  is  meant  simply  that  the  fetus  was  born  alive,  and  the  defi- 
nition of  the  term  is  entirely  independent  of  the  viability  of  the  child,  which 
latter  term  indicates  the  capability  the  child  possesses  of  continuing  to  live. 


FEIGNED  DELIVERY— UNCONSCIOUS  DELIVERY.  449 

A  strict  medico-legal  rendering  of  the  term  live  birth  ignores  entirely  the  imma- 
turity, viability,  and  mat-urity  of  the  child,  and  requires  an  answer  only  to 
the  question,  Was  the  fetus  at  the  moment  of  expulsion  alive?  The  test  of 
a  live  birth  differs  in  various  countries;  in  Germany,  crying  "attested  by 
unimpeachable  witnesses";  in  France,  respiration;  in  Scotland,  crying;  in 
England  and  the  United  States  neither  breathing  nor  crying  is  essential  to 
establish  a  live  birth;  the  pulsation  of  the  child's  heart,  or  of  one  of  its  arteries, 
or  the  slightest  voluntary  movement  is  regarded  as  sufficient  for  this  purpose 
(Reese).  In  regard  to  crying  as  a  test  of  live  birth.  Coke  remarks:  "If  it  be 
born  alive  it  is  sufficient,  though  it  be  not  heard  to  cry,  for  peradventure  it 
may  be  born  dumb."  Legally,  all  we  require  for  a  live  birth  is  anything  to 
prove  that  the  child  was  alive  at  the  time  when  it  entered  the  world. 


IX.  FEIGNED  DELIVERY. 

From  a  variety  of  motives,  as  for  extorting  damages  or  charity,  compelling 
marriage,  disinheritance,  obtaining  admission  to  some  charitable  mstitution, 
or  for  no  assignable  reason,  women  may  simulate  or  feign  delivery  of  a  child. 
A  careful  examination  of  these  cases  if  the  simulated  delivery  is  said  to  be 
recent,  and  if  the  various  doubtful,  probable,  and  certain  signs  of  recent  delivery 
are  excluded,  will  clear  away  all  doubt.*  (See  Signs  of  Recent  Delivery,  Part 
VI.)  This  condition  in  the  lower  animals  is  quite  common,  and  has  been  repeat- 
edly observed  by  dog-breeders.  I  have  observed  the  phenomenon  in  the  breed- 
ing of  Scotch  terriers.  Years  ago  Harvey,  in  writing  upon  conception,  stated 
that  overfed  bitches,  which  admit  the  dog  without  fecundation  following,  are 
nevertheless  observed  to  be  sluggish  about  the  time  they  should  have  whelped, 
and  to  bark  as  they  do  when  their  time  is  at  hand,  also  to  steal  away  the  whelps 
of  another  bitch,  to  tend  and  lick  them,  and  also  to  fight  fiercely  for  them. 
Others  have  milk  or  colostrum  in  their  teats,  and  are,  moreover,  subject  to 
the  diseases  of  those  which  have  actually  whelped. 


X.  UNCONSCIOUS  DELIVERY. 

The  possibility  of  a  woman  giving  birth  to  a  child  even  at  full  term,  and 
remaining,  for  a  time  at  least,  unconscious  of  the  fact,  must  be  granted.  The 
possibility  of  unconscious  delivery  is  especially  important  in  regard  to  the 
subject  of  infanticide;  the  defense  in  these  cases  often  being  that  the  woman 
was  unconscious  of  the  act  of  parturition.  Unconscious  delivery  during  the 
action  of  narcotic  drugs  and  anesthetics,  and  in  women  in  convulsions,  stupor, 
coma,  or  moribund  condition,  is  common,  and  women  have  been  delivered 
unconsciously  during  profound  sleep. f  Unconscious  delivery  during  hysteria 
is  possible,  but  here  as  well  as  during  sleep  it  is  more  than  likely  that  the  pains 

*  Compare  Kost:  "Text-Book  of  Medical  Jurisprudence,"  Cincinnati,  18S5,  p.  1S9 
Goodell,  W.:  "Medical  News,"  Phila.,  1890,  lviii,  pp.  409-411.  "Henke's  Zeitschrift," 
vol.  XLiv,  p.  172.  Fischer,  C.:  "Zeitschr.  f.  Wundartze  u.  Geburtsh.,"  Hegnach,  1887, 
XXXVIII,  pp.  264-268.     "Ein  forensicher  Pseudo-Geburtsfall." 

t  For    cases  of  unconscious  delivery   during  sleep   compare   Weill:       "Gaz.   M6d.   de 
Strasbourg,"  18S1,  i,  x,  p.  103;  Case,  M.  W.:  "American  Journal  Med.  Sciences,"  Phila., 
1886,  Lv,  p.  270;  Samuelson,  A.:  "Brit.  Med.  Jour.,"  London,  1865,  11,  p.  550;  Tamier: 
"Journal  des  Sages-Femmes,"  Juillet  10,  1891. 
29 


450  PHYSIOLOGICAL  LABOR. 

of  the  expulsive  stage  of  labor  would  arouse  the  woman ;  this  is  especially 
true  of  primiparae,  but  every  obstetrician  is  aware  that  in  some  women,  par- 
ticularly multiparae  with  roomy  pelves  and  relaxed  soft  parts,  a  very  few  and 
almost  painless  contractions  of  the  uterus  are  sufficient  to  empty  the  uterus 
rapidly  and  easily.  Perhaps  the  most  frequent  diseased  condition  in  which 
a  woman  may  be  unconsciously  delivered  is  the  stupor,  convulsions,  or  coma 
of  puerperal  eclampsia;  as  is  well  known,  puerperal  mania  often  follows  this 
condition. 

Under  the  preceding  conditions  it  is  quite  possible  for  a  woman  to  be  confined, 
to  injure  or  even  to  kill  her  child,  subsequently  to  be  restored  to  consciousness, 
and  to  be  perfectly  truthful  in  her  assertion  of  her  entire  ignorance  of  what  had 
happened,  and  the  clinical  picture  of  puerperal  albuminuria  or  eclampsia  would 
sustain  her  statements.  Again,  the  expulsion  of  the  child  has  been  mistaken 
for  a  strong  desire  on  the  part  of  the  woman  to  empty  her  bowels ;  this  is  a 
common  defense  set  up  for  the  charge  of  child  murder.  An  intense  desire  to 
empty  the  lower  bowel  accompanies  the  expulsive  stage  of  labor,  and  from 
our  present  knowledge  of  the  subject,  gleaned  from  many  cases  reported  by 
competent  observers,  and  from  personal  cases,  a  woman  may  be  seized  with 
this  intense  desire  to  defecate,  hurriedly  enter  a  water-closet  or  privy,  and 
be  absolutely  ignorant  of  the  act  of  parturition  until  too  late  to  save  the  expelled 
child  from  injury.  Such  accidents  are  possible  and  have  happened.  Before 
the  claim  of  such  an  occurrence  is  accepted  in  a  given  case,  a  thorough  inves- 
tigation should  be  made  by  the  medical  witness,  including  a  vaginal  examina- 
tion of  the  woman  in  question.* 

In  addition,  we  must  bear  in  mind  that  while  the  woman  may  in  a  given 
case  be  unconscious  of  the  expulsion  of  her  child  at  the  moment  of  delivery, 
yet  she  cannot  remain  ignorant  of  the  fact  that  she  has  been  delivered,  if  she 
be  at  the  time  conscious. 


XL  VERTEX  PRESENTATION. 

Definition. — A  vertex  presentation  is,  strictly  speaking,  an  occiput  presenta- 
tion, the  occiput  being  the  region  of  the  fetal- head  behind  the  posterior  fontanelle 
including  and  surrounding  the  external  occipital  protuberances  (Fig.  541). 
When  this  region  forms  the  presenting  part,  there  exists  an  occipital  or  so-called 
vertex  presentation.  This  presentation  affords  the  most  natural  posture  for 
the  fetus,  the  best  opportunities  for  its  favorable  development,  and  at  labor 
the  best  prognosis  for  both  mother  and  child. 

Frequency. — The  frequency  of  vertex  presentations  is  96  per  cent,  of  all 
cases.     Compare  Presentations,  page  423. 

*  I  was  hurriedly  summoned  one  night  to  a  case  of  this  character,  in  which  a  servant  in 
the  family,  a  primipara,  out  of  wedlock,  and  at  or  near  term,  mistook  a  nearly  painless  labor 
for  a  difficult  defecation,  and  the  child  was  born  in  the  pan  of  the  water-closet.  The  patient 
complained  of  lumbo-sacral  pains  and  rectal  pressure  and  denied  any  knowledge  of  the 
escape  of  liquor  amnii.  Attempted  infanticide  was  of  course  suspected,  but  an  investiga- 
tion satisfied  all  that  there  was  no  premeditated  infanticide.  The  child  lived,  and  it  and 
its  mother  were  removed  the  same  night  to  a  hospital. 

In  another  case  I  was  asked  to  see  a  woman  in  a  New  York  tenement  in  which  the  patient, 
a  multipara,  was  delivered  precipitately  on  a  fire-escape,  in  the  act  of  leaning  over  the  rail- 
ing and  exerting  a  good  deal  of  strength  in  drawing  a  clothes-line  loaded  with  clothes  toward 
her;  she  was  unaware  of  labor  until  the  child,  near  term,  struck  the  iron  floor  of  the  fire- 
escape.  The  child  sustained  contusions  of  the  scalp  and  a  depression  of  one  parietal  bone, 
but  sur\ived. 


VERTEX  PRESENTATION.  451 

Etiology. — See  Presentations,  page  423. 
Positions  and  Relative  Frequency. — 

I.     Left  occipito-ahterior,  Occipito-laeva  anterior,  L.  0.  A.,  70  per  cent. 
II.     Right  occipito-anterior,  Occipito-dextra  anterior,  R.  0.  A.,  10  percent. 

III.  Right  occipito-posterior,  Occipito-dextra  posterior,  R.  O.  P.,  17  per  cent. 

IV.  Left  occipito-posterior,  Occipito-lasva  posterior,  L.  0.  P.,  3  per  cent. 
In  vertex  presentations  the  first  position  obtains  in  70  per  cent,  of  cases; 

the  second  in  10  per  cent.;  the  third  in  17  percent.;  and  the  fourth  in  3  per 
cent.  For  the  explanation  of  this  relative  frequency,  compare  Relative  Frequency 
of  Positions,  page  424  (Fig.  577) 

Mechanism. — I.  Left  Occipito-anterior  Position,  L.  0.  A.  (Fig.  586). — 
I .  Flexion  and  Moulding  oj  the  Head. — The  sagittal  suture  in  this  position  cor- 
responds to  the  right  oblique  of  the  pelvic  inlet,  or  possibly  to  a  diameter 
between  this  and  the  transverse.  If  head  flexion  is  complete,  the  suboccipito- 
bregmatic  circumference,  11  inches  (28  cm),  is  in  relation  with  the  circumference 
of  the  parturient  inlet — the  most  favorable  presentation  (Fig.  586) 

Flexion. — Most  authorities  associate  flexion  of  the  head  upon  the  body 
with  this  stage.  Possibly  flexion  is  rendered  more  complete  at  this  time,  but 
a  study  of  frozen  sections  of  pregnancy  and  elective  versions  before  labor  has 
convinced  the  author  that  flexion  is  complete,  or  nearly  so,  before  the  onset 
of  labor.  The  normal  attitude  of  the  fetal  ellipse  during  pregnancy  is  one  of 
flexion  of  all  its  parts  (page  420).  The  causes  of  flexion  prior  and  subsequent 
to  labor  are:  (i)  The  normal  attitude  of  the  fetal  ellipse  during  pregnancy  is  one 
of  flexion  of  all  its  parts.  (2)  This  flexion  of  pregnancy  is  increased  or  completed 
during  moulding  and  entrance  of  the  head  into  the  inlet,  because  the  sincipital  pole 
of  the  head-lever  is  longer  than  the  occipital  pole;  so  that  when  the  head  en- 
counters the  resistance  of  the  parturient  inlet,  the  sincipital  or  long  pole  of  the 
lever  meets  with  greater  resistance  and  ascends,  forcing  the  chin  nearer  the  ster- 
num, and  thus  emphasizing  or  completing  primary  or  gestational  flexion  (see  page 
422)  (Fig.  577).  If  for  any  reason  flexion  be  not  complete,  then  possibly  a  circum- 
ference as  great  as  the  occipito-frontal  (13^  inches — 34.5  cm.)  will  be  in  relation 
with  the  circle  of  resistance  of  the  parturient  inlet.  Complete  antero-posterior 
flexion  of  the  head  is  normally  present  at  this  time,  and  opinions  differ  as  to  the 
occurrence  of  lateral  flexion  or  inclination.  A  lateral  inclination  of  the  fetal 
head  toward  the  maternal  sacrum  bringing  the  sagittal  suture  nearer  to  the  pro- 
montory than  to  the  symphysis  is  termed  Naegele's  obliquity,  or  asynclitism 
(page  523).  When  the  head  descends  with  its  planes  parallel  with  the  pelvic 
planes,  a  synclitic  condition  of  the  head  is  present.  With  normal  pelves  and 
fetuses  the  synclitic  engagement  of  the  head  exists  (Kuneke);  in  labor  with 
deformed  pelves,  especially  with  flattened  pelves,  Naegele's  obliquity  is  some- 
times found  (see  Pelvic  Deformity,  pages  604  and  605).  By  Solayres's  obliquity 
(Fig.  586)  is  understood  the  entrance  of  the  sagittal  suture  into  the  pelvic  inlet 
in  an  oblique  diameter.  Roederer's  obliquity  is  extreme  flexion  of  the  chin  on 
the  sternum  (page  499). 

Moulding. — In  most  labors  adaptation  of  the  skull  to  the  pelvis  is  brought 
about  by  certain  movements  of  the  bones  of  the  cranial  vault  upon  one  another. 
Moulding  is  an  important  and  possibly  an  essential  factor  in  the  mechanism 
of  labor,  since  it  prepares  the  head  for  a  ready  engagement  and  descent,  and 
the  change  in  the  shape  of  the  head  lowers  the  dip  of  the  occipital  pole  of  the 
head  lever  in  the  pelvis,  thus  favoring  and  rendering  more  positive  anterior  rota- 
tion of  the  occiput  later  on.  Post-partum  measurements  show  that  the  greatest 
reductions  in  the  diameters  take  place  in  the  transverse  ones,  which  are  often 


452 


PHYSIOLOGICAL  LABOR. 


lessened  by  twice  the  width  of  the  sagittal  and  frontal  sutures.  The  fontanelles 
also  assist  in  the  compression  of  the  head,  so  that  the  transverse  diameters  are 
often  diminished  from  |-  to  |-  inch  (1.5  to  2  cm.),  and  a  corresponding  elongation 
occurs  in  the  sagittal  diameters,  but  it  can  be  shown  by  a  study  of  many  fetal 
skulls  that  the  changes  in  shape  of  the  skull  in  vertex  presentations  due  to  mould- 
ing consist  not  so  much  in  actual  measurable  changes  in  the  length  of  the  head  as 
in  the  flattening  of  the  region  about  the  brow  and  anterior  fontanelle,  an  arching 
and  greater  prominence  of  the  presenting  part  of  the  parietal  bone,  and,  in  pro- 
longed labors,  a  more  vertical  position  of  the  squamous  portion  of  the  occipital 
bone.  A  summary  of  the  disposition  of  the  bones  of  the  skull  due  to  moulding 
in  vertex  presentation  is  as  follows:  (i)  The  anterior  or  presenting  parietal  bone 
is  the  lowest  presenting  part,  and  it  overlaps  not  only  its  fellow  but  also  the  frontal 
and  occipital  bones.  Thus,  in  the  two  left  positions  of  the  vertex  the  left  or  pos- 
terior parietal  bone  is  over- 
a-4%  ridden  by  the  right;  and  in 

the  two  right  positions  the 
right  or  posterior  parietal 
bone  is  overlapped  by  the 
left  (Figs.  582  to  585).  {2) 
The  half  of  the  frontal  bone 
which  is  posterior  and  to- 
ward the  sacrum  is  overlap- 
ped by  its  neighboring  bones 
and  is  slightly  flattened  by 
the  pressure  of  the  promon- 
tory. (3)  Again  the  anterior 
or  lowest  parietal  bone  bul- 
ges more  and  becomes  more 
prominent,  while  the  poste- 
rior or  higher  parietal  bone, 
which  is  against  the  sacrum, 
is  forced  toward  the  frontal 
bone  and  relatively  flat- 
tened. Thus  the  halves  of 
the  skull  are  somewhat 
asymmetrical  (Figs.  582  to 
585).  (4)  The  portion  of  the  head  which  is  lowest  and  constitutes  the  presenting 
part  is  often  forced  out  into  a  point  and  forms  the  apex  of  a  cone,  the  base  of 
which  corresponds  to  that  plane  which  passes  through  the  parturient  canal  first. 
Thus,  in  the  L.  0.  A.  position  the  suboccipito-bregmatic  circumference  or  plane 
forms  the  base  of  a  cone,  the  apex  of  which  is  the  posterior  superior  angle  of  the 
right  parietal  bone.  This  explains  the  situation  of  the  caput  succedaneum  and 
of  a  cephalhematoma.  In  ordinary  cases  deformity  from  moulding  disappears  in 
one  or  two  days,  and  in  the  more  pronounced  cases  in  two  to  four  days.  In  cases 
of  contracted  pelves  with  excessive  moulding  of  the  head,  permanent  deformity 
may  result  which  perhaps  can  be  positively  determined  only  by  taking  a  cast  of 
the  head,  as  measurements  are  misleading  and  unreliable. 

The  Capitt  Succedaneum. — The  change  in  the  shape  of  the  head  produced  by 
moulding  is  still  further  modified  by  a  swelling  on  that  portion  of  the  presenting 
part  which  is  least  subjected  to  pressure  from  the  canal,  due  to  venous  hyperemia 
and  oedema,  and  termed  the  caput  succedaneum.  (See  Part  IX.)  In  the  L.  O.  A. 
position  the  caput  forms  upon  the  posterior  superior  angle  of  the  right  parietal 


(96-9a?i) 

Fig.  577. — Diagram  showing  the  Relative  Frequency 
OF  THE  Positions  of  Vertex  Presentation. 


VERTEX  PRESENTATION. 


453 


bone,  encroaching  somewhat  upon  the  small  fontanelle  and  occipital  bone  (Fig. 
587).  Wrinkling  of  the  scalp  usually  precedes  the  formation  of  the  tumor,  and 
is  indicative  of  commencing  pressure.  The  scalp  tumor  may  form  within  the  bag 
of  membranes  before  their  rupture ;  after  rupture  of  the  membranes  while  the  cer- 
vix is  only  partly  dilated;  and,  thirdly,  at  the  vaginal  outlet  after  the  head  reaches 
the  pelvic  brim.  In  the  first  two  instances  the  caput  is  usually  small  and  of  little 
practical  importance,  but  at  the  vaginal  outlet,  where  it  usually  forms,  it  may 
attain  considerable  size,  and  may  enable  one  after  delivery  to  diagnose  the  posi- 
tion the  head  occupied  within  the  birth  canal.  While  it  is  true  that  in  normal 
labor  the  caput  most  often  forms 
within  the  birth  canal,  still  in  con- 
tracted pelves,  by  reason  of  the  re- 
sistance of  the  pelvic  inlet,  an  enor- 
mous scalp  tumor  may  form  before 
the  head  enters  the  bony  pelvis. 
Upon  the  sinciput  the  caput  is  usu- 
ally larger  than  when  situated  upon 
the  occiput,  partly  by  reason  of  the 
greater  laxity  of  the  tissues  in  the 
former  situation,  and  partly  be- 
cause of  the  longer  duration  of 
labor  when  the  sinciput  is  directed 
to  the  front.  In  size  the  diameter 
may  vary  from  one  to  two  inches 
(2.5  to  5  cm.)  or  more.  In  left  occi- 
pito-anterior  positions  the  caput 
forms  upon  the  superior  posterior 
angle  of  the  right  parietal  bone, 
overlapping  somewhat  the  small 
fontanelle  and  occipital  bone;  in 
right  occipito-anterior  positions, 
upon  the  corresponding  point  of  the 
left  parietal  bone ;  in  right  occipito- 
posterior  positions  the  tumor  de- 
velops upon  the  anterior  superior 
angle  of  the  left  parietal  bone, 
sometimes  overlapping  the  frontal 
suture;  in  left  occipito-posterior 
positions  we  find  the  caput  upon 
the  anterior  superior  angle  of  the 
right  parietal  bone,  also  often  over- 
lapping the  frontal  suture.  In  in- 
stances of  a  moderately  rapid  labor  up  to  the  time  the  head  reaches  the  pelvic 
floor,  and  in  instances  in  which  the  internal  rotation  of  the  head  has  been  com- 
plete and  the  head  is  detained  for  a  long  period  at  the  vaginal  outlet,  a  large  caput 
succedaneum  often  forms  directly  in  the  median  line  over  the  sagittal  suture,  and 
thus  possibly  obscures  the  diagnosis. 

2.  Engagement  and  Descent  of  the  Head  (Fig.  586). — It  must  be  remembered 
that  flexion,  engagement,  and  descent  of  the  head  are  often  completed  before 
labor  actually  sets  in,  this  being  specially  true  of  primigravidae  (see  Engagement 
and  Descent,  page  441 ).  In  these  cases  of  ante-partum  engagement  and  descent, 
head-flexion  is  completed  or  emphasized  in  the  transit  of  the  head  through  the 


Fio.  578. — Diagram  showing  the  Relation  of 
THE  Lever-like  Action  of  the  Head  to  the 
'Fetal  Axis. 


454 


PHYSIOLOGICAL  LABOR. 


MOULDING  IN  VERTEX  PRESENTATION. 
ANTERIOR   POSITIONS 


Fig.  579. — Before  Moulding. 


Fig.  580. — ^Moderate  ^Ioui.ding. 


Excessive  ^vIoulding. 


cervix.  Exceptionally  because  of  a 
small  head,  or  a  softened  and  com- 
pletely dilated  cervix, — the  latter  in 
multiparae, — the  ring  of  the  cervix 
does  not  enter  as  a  factor  into  the 
causation  of  flexion.  In  exceptional 
cases  only  is  Naegele's  obliquity  pres- 
ent, and  usually  the  head  enters  the 
pelvis  in  the  axis  of  the  inlet  with  the 
biparietal  diameter  parallel  with  the 
plane  of  the  inlet,  and  this  relation  of 
the  head  to  the  successive  planes  of 
the  pelvis  is  maintained  until  the  pel- 
vic floor  is  reached.  Engagement  and 
descent  go  hand-in-hand,  and  the  ease 
and  promptness  with  which  the  latter 
is  accomplished  will  depend  upon 
the  resistance  encountered  at  the 
barrier  of  the  cervix  and  in  the  walls 
of  the  pelvis  and  vagina. 

3.  Anterior  Rotation  of  the  Occiput 
(Figs.  588  and  589). — Descent  con- 
tinues until  the  most  dependent  por- 
tion of  the  presenting  part — the  occi- 
put— reaches  the  pelvic  floor.  For 
reasons  already  set  forth  (page  442), 
anterior  rotation  of  the  occiput  occurs 
so  that  it  turns  forward  under  the 
pubic  arch,  and  the  sagittal  suture  oc- 
cupies very  nearly  the  antero-poste- 
rior  diameter  of  the  bony  pelvic  outlet 
(Fig.  590).  Excessive  rotation:  We 
occasionally  see  excessive  internal  ro- 
tation of  the  head,  by  which  is  meant 
that  the  sagittal  suture  rotates  from 
one  oblique  pelvic  diameter  past  the 
conjugate  and  into  the  opposite  ob- 
lique. This  is  probably  in  conse- 
quence of  excessive  rotation  of  the 
trunk,  due  to  strong  uterine  contrac- 
tions compressing  the  fetal  back  and 
turning  it  toward  the  front  and  oppo- 
site side.  In  my  sixty-nine  observa- 
tions in  primiparse,  and  seventy-one 
in  multiparae,  excessive  rotation  of 
the  head  from  one  oblique  diameter 
to  the  other  occurred  in  but  one  in- 
stance— a  primipara.* 

4.  Extension  and  Expulsion  of  the 
Head  (Figs.  574  and  575). — Rotation 


♦Edgar:  "The  Mechanism  of  Labor;  Some  Experimental  and  Clinical  Observations," 
"Amer.  Joum.  Obstet.,"  vol.  xxviii,  No.  4,  1893. 


VERTEX  PRESENTATION. 


455 


being  complete,  there  comes  a  time 
when,  the  occiput  having  passed 
under  the  subpubic  ligament  and 
being  partially  born,  the  shoulders 
attempt  to  enter  the  pelvis  with  the 
head;  and  as  under  ordinary  cir- 
cumstances there  is  not  sufficient 
room  for  both,  the  head  escapes 
from  the  vulva  by  a  movement  of 
extension.  This  is  not  strictly  true, 
for  repeated  observations  show 
that  part  of  the  head,  including  the 
occiput,  is  bom  before  the  chin 
leaves  the  sternum,  a  fact  we  must 
always  remember  in  our  attempts 
at  perineal  protection  and  forceps 
delivery  (Fig.  573).  This  escape 
of  the  head  is  caused  by  the  force 
of  uterine  contraction  acting 
through  the  spinal  column  and 
by  the  contraction  of  the  muscles 
that  go  to  make  up  the  pelvic 
floor ;  and  we  see  the  beautiful  pro- 
vision of  nature  that  has  caused 
only  the  smallest  circumference — 
namely,  the  suboccipito-bregmatic, 
13  inches  (33  cm.) — to  be  passed 
through  the  birth  canal;  and  even 
at  the  vulva,  the  occiput  having 
been  born  first,  all  the  circumfer- 
ences of  the  fetal  head  that  pass 
in  succession  through  the  vulval 
opening  are  measured  not  from  the 
occipital  protuberance,  which  is  al- 
ready born,  but  from  a  point  mid- 
way between  it  and  the  foramen 
magnum,  and  are  consequently  the 
smallest  or  the  suboccipital  circum- 
ference (Fig.  574). 

5.  Rotation  of  the  Trunk  and 
Restitution  of  the  Head. — The  right 
or  lower  shoulder  rotates  to  the 
pubis  and  the  face  looks  toward 
the  right  thigh  of  the  mother.  (See 
Mechanism,  page  447.) 

6.  Expulsion  of  the  Trunk. — We 
have  now  followed  the  bisacromial 
diameter  into  the  antero-posterior 
diameter  of  the  pelvic  outlet.  The 
involuntary  and  voluntary  forces 
direct  the  shoulders  into  the  par- 
turient outlet.     Shoulder  delivery: 


MOULDING  IN  VERTEX  PRESENTATION. 
(AUTHOR'S   COLLECTION   OF    SKULLS.) 


Fig.   582.— Left 


Posterior   View 


Fig.    5S3. — Left    Position.      Anterior  View. 


Fig,  584. — Right  Position.     Posterior  View, 


Fig.  585. — Right  Position.     Anterior  View. 


456 


PHYSIOLOGICAL  LABOR. 


VERTEX  PRESENTATION. 

FIRST  VERTEX  POSITION. 

LEFT  OCCIPITO-ANTERIOR,  L.  O.  A. 


Fig.  586. — At  Pelvic  Inlet. 


Fig.  587. — Right  Parietal  Bone  in  the 
Cervix. 


Fig.   588. — Head    at    Pelvic   Floor  be- 
fore Rotation. 


The  right  or  anterior  shoulder,  whether 
it  does  or  does  not  appear  first  under 
the  arch  of  the  pubis,  is  usually  de- 
tained at  this  point,  and  the  posterior 
or  left  or  perineal  shoulder,  with  arm 
and  forearm,  are  propelled  over  the  edge 
of  the  perineum  and  born,  their  escape 
being  followed  by  the  delivery  of  the 
right  or  pubic  shoulder  and  arm  (Fig. 
620).  With  the  birth  of  the  shoul- 
ders the  arms,  forearms,  and  hands  are 
usually  found  flexed  upon  the  child's 
chest,  as  they  are  found  in  the  normal 
attitude  (see  page  420).  The  shoulders 
having  been  delivered,  the  body  usu- 
ally follows  immediately  after.  Some 
obstetricians  would  speak  of  a  stage  of 
rotation  of  the  buttocks,  but  there  is 
every  reason  to  believe  that  when  the 
shoulders  rotate  the  buttocks  rotate 
with  them,  in  ordinary  cases,  and  con- 
sequently there  is  little  or  no  torsion 
of  the  body,  but  the  buttocks  come 
down  and  are  expelled  in  the  antero- 
posterior diameter  of  the  outlet  in 
practically  the  same  way  as  are  the 
shoulders. 

IL  Right  Occipito-anterior  Posi- 
tion, R.  0.  A.  (Fig.  591). — (i)  Flexion 
and  moulding  of  the  head:  This  stage  in 
the  mechanism  is  the  same  as  in  the  L. 
0.  A.  position,  except  that  the  caput 
forms  upon  the  posterior  superior  angle 
of  the  left  parietal  bone  and  the  shape 
of  the  head  and  the  overlapping  of  the 
bones  differ  (Fig.  592).  (2)  Engagement 
and  descent:  The  sagittal  suture  enters 
the  left  oblique  diameter  of  the  pelvic 
inlet  and  descent  occurs  as  before  until 
the   pelvic    floor  is  reached  (Fig.  593). 


Fig. 


. — Head  at  Pelvic  Floor  after 
Anterior  Rotation. 


Fig.  590. — In  the  Vulva,  with  Incomplete 
Anterior  Rotation. — {From  a  photograph.) 


VERTEX  PRESENTATION. 


457 


SECOND  VERTEX  POSITION. 
RIGHT  OCCIPITO-ANTERIOR,  R.  O.  A. 


Fig.  591. — At  Pelvic  Inlet. 


Pig.  592. — -Left  Parietal  Bone  in    the 
Cervix. 


Fig. 


593. — Head   at  the   Pelvic   Floor 
BEFORE  Anterior  Rotation. 


(3)  Anterior  rotation  of  the  occiput:  This 
occurs,  for  reasons  already  stated,  from 
right  to  left  instead  of  from  left  to  right 
as  in  the  L.  0.  A.  position    (Fig.   593). 

(4)  Extension  and  expulsion  of  the  head 
are  the  same  as  in  the  L.  0.  A.  position. 

(5)  Rotation  of  the  trunk:  The  bisacro- 
mial  diameter  of  the  shoulders  enters  the 
right  oblique  diameter  of  the  pelvic  inlet 
and  the  rotation  of  the  trunk  causes  the 
left  shoulder  to  come  under  the  pubic 
arch.  (6)  Expulsion  of  the  trunk  is  the 
same  as  in  the  L.  0.  A.  position,  as 
regards  anterior  and  posterior  shoulder 
delivery  (Fig.  620). 

III.  Right  Occipito-posterior 
Position,  R.  0.  P.  (Fig.  596). — i.  Flex- 
ion and  Moulding  of  the  Head. — This 
stage  is  the  same  as  in  the  R.  O.  A. 
position,  except  that  the  flexion  is  liable 
to  be  imperfect.  The  caput  succedaneum 
develops  upon  the  anterior  superior 
angle  of  the  left  parietal  bone,  some- 
times overlapping  the  frontal  suture 
(Fig.  597),  and  the  shape  of  the  head 
and  the  overlapping  of  the  bones  differ 
(Figs.  584  and  585). 

2.  Engagement  and  Descent  of  the 
Head. — The  suboccipito-bregmatic  di- 
ameter in  this  position  enters  the  inlet 
in  its  right  oblique  diameter.  Following 
engagement  we  have  descent,  in  some 
cases  until  the  pelvic  floor  is  reached, 
and  in  others  anterior  rotation  of  the 
vertex  occurs  before  the  pelvic  floor 
is  reached.  In  these  latter  instances 
there  is  every  reason  to  believe  that 
it    is    the    resistance   of   the    posterior 


Fig.   594. — Heae)    at   the    Pelvic  Floor 
before  Anterior  Rotation. 


Fig.  595. — Head  Expulsion  after  Anterior 
Rotation. — (From  a  photograph.) 


458 


PHYSIOLOGICAL  LABOR. 


THIRD  VERTEX  POSITION. 

Right  Occipito-Posterior,  R.  O. 


P. 


Fig.  596. — At  the  Pelvic  Inlet. 


wall  of  the  uterus  or  of  the  recto-vaginal  septum  that  determines  this  early 
rotation  (Fig.  530). 

3.  Rotation  of  the  Occiput. — When  once  the  vertex  has  reached  the  pelvic 
floor,  the  case  may  terminate  in  one  of  four  ways,  and,  in  order  of  frequency, 
they  are  as  follows:  First,  complete  anterior  rotation  of  the  occiput  about  the 

right  half  of  the  pelvis  until  the  pubis 
is  reached;  second,  posterior  rotation  of 
the  vertex  into  the  hollow  of  the  sacrum 
and  birth  of  the  head  with  the  occiput 
to  the  rear  by  extension  over  the  peri- 
neum; third,  posterior  rotation  and  im- 
paction; and,  fourth,  the  conversion  of 
the  vertex  presentation  into  one  of  face 
presentation;  and  although  this  latter 
termination  is  extremely  rare,  some  in- 
stances of  it  are  on  record,  and  we  are 
compelled  to  recognize  its  possibility 
(Fig.  538).  (1)  Anterior  rotation:  It  is 
unnecessary  to  describe  the  first  method 
of  termination ;  the  same  principles  apply 
heie  as  in  the  first  and  second  positions. 
The  greater  resistance  of  the  posterior 
segment  of  the  pelvic  floor  causes  the 
occiput  to  be  deflected  in  the  direction 
of  least  resistance — namely,  to  the  vul- 
val orifice  (Fig.  599).  (2)  Posterior  rota- 
tion and  birth  of  the  occiput  over  the  peri- 
neum: Instances  occur,  however,  in 
which  from  some  cause,  as  roominess  of 
the  pelvis,  smallness  of  the  child,  want 
of  rigidity  of  pelvic  floor  from  numerous 
labors,  or  other  causes, — distention  of 
the  floor  by  the  passage  of  the  first  twin, 
incomplete  flexion  of  the  head,  permit- 
ting the  sinciput  to  be  as  low  as  or  lower 
than  the  occiput, — anterior  rotation 
fails.  Most  authorities  state  this  to 
be  a  rare  condition,  yet  according  to 
Naegele's  statistics  it  occurred  once  in 
73  cases  of  labor.  In  2200  labors  I 
found  persistent  occipito-posterior  posi- 
tion to  occur  in  89  cases  of  labor,  or 
4.04  per  cent.  Should  anterior  rotation 
fail  and  the  occiput  remain  in  the  pos- 
terior half  of  the  pelvis,  it  is  possible 
under  certain  conditions  for  the  occiput 
to  follow  the  posterior  wall  of  the  par- 
turient canal  and  to  be  born  by  extension  over  the  edge  of  the  perineum. 
Labor  then  is  almost  always  prolonged,  and  in  some  instances  impossible  as  the 
result  of  impaction  (Fig.  601 ).  The  cause  of  the  prolongation  of  the  labor  under 
such  circumstances  was  first  pointed  out  by  P.  Dubois,  and  is  readily  understood. 
The  back  of  a  child's  neck  (Fig.  544)  is  not  much  over  3  inches  (7.5  cm.)  in 


Fig   597. 


-Left  Parietal  Bone  in  the 
Cervix. 


Fig. 


598. — Vertex  at  the  Pelvic  Floor 
BEFORE  Anterior  Rotation. 


VER  TEX   PRESENT  A  TION. 


459 


THIRD  VERTEX  POSITION.— (Cont.) 


Fig.  599. — Vertex  at  the  Pelvic  Floor 
BEFORE  Anterior  Rotation. 


i?^'>-' 


length;  the  posterior  wall  of  the  parturient  canal,  from  the  promontory  of  the 
sacrum  to  the  edge  of  the  perineum  (Fig.  516),  is  in  the  neighborhood  of  ten 
inches  (25  cm.),  counting  five  inches  from  the  promontory  to  the  tip  of  the 
coccyx  and  five  more  from  this  point  to  the  edge  of  the  distended  pelvic  floor. 
If  an  anterior  position  of  the  vertex  obtains,  the  birth  of  the  head  is  readily 
and  easily  accomplished;  for  the  two 
inches  of  the  back  of  the  neck  without 
any  difficulty  pass  over  the  if  inches 
(4  cm.)  of  the  anterior  pelvic  wall  meas- 
ured at  the  symphysis,  and  the  head  is 
born  before  the  shoulders  necessarily 
enter  the  pelvic  inlet.  For  the  head  to 
be  born  in  an  occipito-posterior  posi- 
tion we  may  hope  for  no  break  in  the 
straight  and  rigid  mass  that  the  fetus 
represents,  until  the  head  together  with 
the  neck  has  traversed  the  ten  inches 
of  the  posterior  pelvic  and  perineal  walls, 
and  the  head  is  finally  permitted  to  be 
born  over  the  perineum.  Delivery  under 
such  circumstances  is  certainly  possible 
by  the  natural  forces,  for  after  an  exceed- 
ingly tedious  labor  and  extreme  flexion 
of  the  head  on  the  sternum,  and  the  occi- 
put distending  the  pelvic  floor  for  several 
hours,  finally  with  tremendous  bearing- 
down  efforts  on  the  part  of  the  parturient 
woman,  the  occiput  is  enabled  to  climb 
up,  as  it  were,  over  the  edge  of  the  peri- 
neum, the  forehead  and  face  appear  at 
the  pubes,  and  the  perineum  slipping  by 
the  occiput  and  along  the  neck,  extension 
completes  the  birth  of  the  head.  (3)  Pos- 
terior rotation  and  impaction:  Unfortun- 
ately we  occasionally  meet  with  instances 
in  which  anterior  rotation  of  the  occiput 
or  spontaneous  delivery  of 'the  occiput 
to  the  rear  both  fail  to  occur.  And  if  we 
have  added  an  impaction  and  swelling  of 
the  shoulders  that  have  partially  entered 
the  pelvic  cavity,  we  have  one  of  the 
tragedies  of  midwifery  practice.  Given 
a  normal-sized  fetus,  a  pelvis  of  ordinary 
dimensions,  perhaps  a  primipara  with 
rigid  soft  parts,  and  the  cause  of  impac- 
tion of  those  cases  of  occipito-posterior 

position  that  have  been  improperly  treated  in  the  early  second  stage  of  labor  is 
easily  understood.  The  occiput  passes  into  the  hollow  of  the  sacrum,  reaches 
the  coccyx  perhaps,  but  still  is  several  inches  (5  inches)  from  the  edge  of  the 
perineum.  Under  the  circumstances  the  body  of  the  child  must  enter  the  pelvic 
cavity  with  the  head  in  order  to  allow  of  the  occiput's  reaching  the  edge  of  the 
perineum.    We  have  impaction  then  because  the  dorso-sternal  diameter,  3!  inches 


}i 


Fig.    600. — Restitution    of    t 
after    Anterior    Rotation 

PULSION. 


iE     He/\d 

AND      Kx- 


FiG.  601. — Delivery  of  the  Head  after 
Posterior  Rotation  of  the  Occiput. 


460 


PHYSIOLOGICAL  LABOR. 


FOURTH   VERTEX   POSITION. 
LEFT  OCCIPITO-POSTERIOR,  L.  O.  P. 


/ 


Fig.  602. — At  Pelvic  Inlet. 


(9.5  cm.)  (Fig.  544),  is  added  to  the  fronto-mental  diameter,  3^  inches  (8.25  cm.) 
(Fig.  533),  giving  an  antero-posterior  diameter  of  the  presenting  fetal  mass  of  7 
inches  (17.78  cm.)  that  the  uterine  forces  are  attempting  to  drive  through  a  pelvis 
the  average  diameter  of  which  is  usually  not  more  than  4!  inches  (12  cm  )  (Fig. 

509).  And  this  is  not  all;  the  length  of 
the  fetal  ellipse  when  the  child  is  in  nor- 
mal attitude  is  half  the  length  of  the 
entire  fetus — namely,  about  11  inches 
(27.5  cm.);  consequently  when  the  occi- 
put has  come  to  the  edge  of  the  peri- 
neum the  breech  of  the  child  has  practi- 
cally entered  the  inlet  of  the  pelvis,  and 
the  uterus  under  such  circumstances  can- 
not but  act  at  a  disadvantage.  We  can 
readily  see,  then,  what  either  spontane- 
ous or  artificial  birth  of  the  fetus  means 
to  the  mother — almost  invariably  a  par- 
tial or  complete  loss  of  her  perineal  struc- 
tures, or  uterine  inertia  and  exhaustion 
(Fig.  601 ).  (4)  Conversion  into  a  face  pre- 
sentation: The  fourth  manner  in  which 
this  posterior  position  may  terminate  is 
for  the  occiput  in  some  way  to  become 
arrested  in  its  course,  and  then,  the  chin 
leaving  the  sternum,  rotation  on  a  bi- 
parietal  diameter  takes  place,  the  head, 
as  it  were,  turns  a  somersault,  becomes 
extended  within  the  pelvic  cavity,  and 
we  have  resulting  a  face  presentation  of 
the  mento-anterior  variety.  This  is  of 
rare  occurrence  spontaneously.  A  few 
manual  conversions  of  an  occipito-pos- 
terior  position  into  a  face  presentation 
within  the  pelvis  have  been  reported. 

4  Expulsion  of  the  Head. — If,  as  hap- 
pens in  all  but  1.5  per  cent  of  cases,  an- 
terior rotation  of  the  occiput  about  the 
right  half  of  the  pelvis  to  the  pubis 
occurs,  the  head  delivery  is  the  same  as 
in  the  R.  O.  A.  position  (Fig.  606). 

5.  Rotation  of  the  Trunk. — The  shoul- 
ders enter  the  pelvis  with  the  bisacromial 
diameter  in  the  left  oblique  pelvic  diam- 
eter, and  the  left  anterior  or  lowest  shoul- 
der naturally  rotates  to  the  pubis. 

6.  Expulsion  of  the  Trunk. — After 
shoulder  rotation  this  is  the  same  as  in 
the  R.  0.  A.  position. 

IV.  Left  Occipito-posterior  Position,  L.  O.  P.  (Fig.  602). — (i)  Flexion 
and  moulding  of  the  head:  This  stage  is  the  same  as  in  the  L.  0.  A.  position, 
except  that  the  flexion  is  liable  to  be  imperfect,  the  caput  succedaneum  develops 
upon  the  anterior  superior  angle  of  the  right  parietal  bone,  often  overlapping  the 


Fig. 


603. — Right  Parietal  Bone  in  the 
Cervix. 


Fig.  604. — Vertex  at  the  Pelvic  Floor 
BEFORE  Anterior  Rotation  of  the 
Occiput. 


VERTEX  PRESENTATION. 


461 


FOURTH  VERTEX  POSIT10N.-(Cont.) 


frontal  suture  (Fig.  603),  and  the  shape  of  the  head  and  overlapping  of  the 
bones  differ  somewhat  (Figs.  -582  and  583).  (2)  Engagement  and  descent  of  the 
head:  The  suboccipito-bregmatic  diameter  in  this  position  enters  the  left  oblique 
diameter  of  the  inlet  (Fig.  602).  Descent  now  occurs  as  in  the  L.  0.  A.  position 
(page  453).  (3)  Rotation  of  the  occiput:  The  same  general  principles  govern  the 
further  progress  as  in  the  R.  O.  P.  posi- 
tion, except  that  backward  rotation  in 
the  1.5  percent,  would  occur  from  left  to 
right,  and  the  anterior  rotation  which 
usually  occurs  takes  place  around  the  left 
side  of  the  pelvis  to  the  pubis  (Figs.  604 
and  605 ) .  Delivery  or  impaction  in  occi- 
pito-posterior  cases  is  the  same  as  in  the 
R.  0.  P.  position  (page  458).  (4)  Expul- 
sion of  the  head:  If,  as  happens  in  all  but 
1.5  per  cent,  of  cases,  anterior  rotation  of 
the  occiput  about  the  left  half  of  the  pel- 
vis to  the  pubis  occurs,  the  head  delivery 
is  the  same  as  in  the  L.  0.  A.  position 
(Fig.  590).  (5)  Rotation  of  the  trunk:  The 
bisacromial  diameter  enters  the  right  ob- 
lique diameter  of  the  inlet,  and  the  right 
or  anterior  or  lowest  shoulder  naturally 
rotates  to  the  pubis  (Fig.  576).  (6)  Ex- 
pulsion of  the  trunk:  After  shoulder  rota- 
tion this  is  the  same  as  in  the  L.  0  A. 
position  (Figs.  620  and  621). 

Diagnosis. — One  may  be  required  to 
make  the  diagnosis  of  vertex  presenta- 
tion (i)  during  pregnancy,  (2)  during 
labor,  (3)  after  labor  has  been  com- 
pleted. 


Fig.  605. — -Vertex  at  the  Pelvic  Floor 
BEFORE  Anterior  Rotation  of  'the 
Occiput. 


r 


Fig. 606. — Expulsion  of  thb'Head  after 
Anterior  Rotation  of  the- Occiput. 


1.  During  Pregnancy  (see  table  on 
page  463). — The  diagnosis  of  vertex  pre- 
sentation during  pregnancy  before  the  os 
is  sufficiently  dilated  to  permit  of  distin- 
guishing sutures  or  fontanelles,  or  the 
character  of  the  presenting  part,  is  made 
by  external  or  abdominal  palpation  (see 
page  463). 

2.  During  Labor. — Abdominal  pal- 
pation may  be  carried  out  as  well  during 
labor  between  the  pains.  When  labor 
has  advanced  far  enough  for  us  to  pal- 
pate the  vault  of  the  skull,  the  diagnosis 
of  vertex  positions  is  made  from  the  posi- 
tion and  character  of  the  fontanelles  and  sutures  which  we  can  palpate.  Vertex 
presentations  are  recognized  by  the  characteristic  sensation  of  a  hard  and  globular 
head,  which  soon  becomes  familiar  to  the  student.  The  diagnosis  of  the  position 
must  be  made  by  mapping  out  the  sutures  and  fontanelles.  This  is  apt  to  puzzle 
the  beginner,  and  is  sometimes  difficult  for  the  experienced  obstetrician,  and  can 
be  learned  only  by  practice  upon  the  manikin  and  at  the  bedside  (see  Figs.  587  and 


Fig.  607. — Restitution  of  the  Head. 


462 


PHYSIOLOGICAL  LABOR. 


592).  On  entering  the  os  uteri  the  finger  usually  finds  first  the  anterior  parietal 
bone,  and  behind  this  the  sagittal  suture.  Taking  this  suture  as  the  chief  land- 
mark, and  remembering  that  it  has  a  fontanelle  at  each  end,  the  examining  finger 
undertakes  to  find  these  fontanelles  or  one  of  them.  Following  the  sagittal  suture 
downward  -and  forward,  the  small  (occipital)  fontanelle  is  found  toward  the 
mother's  left  if  the  position  be  an  L.  0.  A.,  or  toward  her  right  if  it  be  an  R.  O. 
A.  The  beginner  should  not  forget  that  the  small  fontanelle,  as  soon  as  the 
uterine  contractions  commence  to  force  the  head  into  the  pelvic  brim,  is  not  an 
opening,  but  only  an  angle  formed  by  the  posterior  borders  of  the  parietal 
bones  and  the  anterior  edge  of  the  occipital.  Following  the  sagittal  suture 
back  from  the  posterior  fontanelle,  the  finger  may  reach  the  large,  soft 
anterior  fontanelle,  and  the  student  should  not  be  satisfied  with  his  diagnosis 
unless  he  has  recognized  both  fontanelles.  If  the  head  is  well  flexed,  the  pos- 
terior fontanelle  may  be  the  first  thing  encountered  by  the  finger,  and  the  ante- 
rior fontanelle  may  be  so  far  back  that  to  reach  it  is  difficult.     Important  points 

for  the  student  to  remember  are 
that  from   the  posterior  fonta- 
nelle run  three  sutures,  from  the 
anterior   fontanelle,    four;    that 
a     posterior     fontanelle     easily 
reached  denotes  good  flexion  of 
the  head,  and  that  an  anterior 
fontanelle  easily  reached  denotes 
small   size  of  head,  incomplete 
flexion,  bregma  presentation,  or 
a  posterior  position  of  the  occi- 
put.    An  exact  diagnosis  by  su- 
tures  and  fontanelles   is  by  no 
means  essential  in  every  appar- 
ently normal  case  before  rupture 
of  the  membranes,  and  to  insist 
upon  it  is  to  expose  the  patient 
to  the  danger  of  premature  rup- 
ture of  the  membranes  and  sep- 
tic infection.     Palpation  of  the 
anterior  or  lower  ear  is  a  valu- 
able diagnostic  sign  (Fig.   608). 
3.  After  Labor. — After  labor  is  completed  we  are  sometimes  called  upon,  for 
medico-legal  purposes,  to  express  an  opinion  regarding  the  presentation  in  which 
the  child  was  born      We  usually  rely  on  two  points  in  making  the  diagnosis  of 
presentation  at  this  time.     First,  the  shape  of  the  child's  head;  and,  second,  the 
position  of  the  caput  succedaneum.     When  labor  has  been  rapid,  when  there  has 
been  no  caput,  and  when  little  or  no  moulding  has  occurred,  there  is  nothing  by 
which  we  may  be  enabled  to  express  a  positive  opinion,  and  there  is  nothing  in 
the  genital  canal  of  the  woman  to  aid  us  in  making  our  diagnosis. 

Prognosis. — Vertex  presentation  offers  the  best  prognosis  for  both  mother 
and  child,  but  it  varies  slightly  with  the  position, — the  anterior  being  more  favor- 
able than  the  posterior,  since  in  the  latter  cases  the  labors  are  generally  longer  and 
more  difficult,  while  the  forceps  is  necessary  about  once  in  seven  cases.  The  soft 
parts  are  more  frequently  torn.  The  maternal  mortality  is  less  than  i  per  cent, 
when  the  case  is  intelligently  managed.  The  fetal  mortality  is  5  per  cent,  in  ante- 
rior vertex  positions,  and  is  increased  to  over  9  per  cent,  in  posterior  positions. 


Fig.  608. — The  Palpation  of  the  Anterior  or 
Lowest  Ear  of  the  Fetus  as  a  Means  of  Posi- 
tive Diagnosis  of  the  Position. 


THE  MANAGEMENT  OF  LABOR. 
DIAGNOSIS   OF   VERTEX    POSITIONS. 


463 


Position  of  Fetus. 


Position  of  Fetal 
Hhart-sounds. 


Left  occipito-anterior,    Occiput  to  left  acetabulum,  forehead  to     Below  and  to  the  left  of 
L.  O.  A.  right    sacro-iliac    joint;  back   to    left;        umbilicus. 

extremities  to  right,  above. 


Right      occipito-ante-  ^  Occiput  to  right  acetabulum,  forehead     Near  median  line,  below 
rior,  R.  O.  A.  to  left  sacro-iliac  joint;  back  to  right;        umbilicus, 

extremities  to  left,  above.  i 


Right     occipito-poste- 
rior,  R.  O.  P. 


Left       occipito-poste- 
rior,  L.  O.  P. 


Occiput  to  right  sacro-iliac  joint,  fore- 
head to  left  acetabulum ;  back  in  right 
flank;  extremities  to  left,  anteriorly. 


In  right  flank,  below  a 
transverse  line  through 
umbilicus. 


Occiput  to  left  sacro-iliac  joint,  forehead  I  In    left    flank,    below    a 

to    right     acetabulum;  back    in    left       transverse  line  through 
flank;  extremities  to  right,  anteriorly.       umbilicus. 


XII.  THE  MANAGEMENT  OF  LABOR. 

Imitation  of  nature  is  the  key  to  the  management  of  normal  labor.  By 
management  is  not  meant  interference,  but  watchful  observation.  A  proper 
understanding  of  this  fundamental  principle  will  serve  to  do  away  with 
much  meddlesome  and  injurious  practice.  In  fact,  it  is  not  to®  much  to  say 
that  in  normal  cases  the  object  of  the  accoucheur  is  to  find  out,  not  how  much, 
but  how  little  interference  is  justifiable.  The  desire  of  the  student  to  see  and 
to  study  abnormal  cases  should  be  restrained  until  he  has  become  thoroughly 
familiar  with  the  phenomena  and  natural  course  of  normal  labor.  It  is  scarcely 
an  exaggeration  to  state  that  the  greater  proportion  of  the  morbidity  if  not 
the  mortality  of  child-birth  is  due  to  the  careless  and  unskilful  management 
of  normal  labor.  Meddlesome  midwifery,  sins  of  commission,  may  be  dangerous ; 
it  is  equally  so  in  obstetrics  to  adhere  too  closely  to  the  modem  dictum,  that 
there  shall  be  no  interference  without  a  positive  indication.  Let  him  or  her 
beware  who  adopts  the  latter  course  and  follows  it  without  a  thorough  famil- 
iarity with  the  physiological  processes  of  normal  labor  and  the  many  and  varied 
dangers  which  may  suddenly  and  unexpectedly  arise  during  child-birth.  Imita- 
tion and  a  watchful  expectancy,  not  a  blind,  unreasoning  trust  in  the  processes 
and  powers  of  nature,  should  guide  us  in  the  management  of  labor.  What 
apparently  begin  as  the  simplest  labors  will  often  subsequently  demand  active 
interference  on  the  part  of  the  attendant.  The  whole  process  of  labor,  properly 
considered,  is  a  conservative  process  the  tendency  of  which  is  to  prevent  sepsis, 
and  it  should  be  our  aim  not  to  thwart  this  process  or  supplant  it  by  methods 
of  art,  but  to  follow  and  aid  it,  interfering  only  when,  for  one  reason  or  another, 
the  resources  of  nature  prove  insufficient.  Nature's  processes  in  labor  are 
from  within  outward.  The  fetus  starts  on  its  journey  through  the  parturient 
canal  from  the  sterile  uterine  cavity,  passes  through  the  aseptic  cervix,  continues 
on  its  way  through  the  vagina,  a  tube  which  while  often  containing  bacteria. 


464  PHYSIOLOGICAL  LABOR. 

even  of  those  species  which  are  sometimes  pathogenic,  may  still  be  regarded  as 
sterile  in  the  majority  of  cases,  and  only  at  the  point  of  final  expulsion  comes 
in  contact  with  a  surely  septic  surface,  at  a  time  when  such  contact  can  do  no 
harm.  In  other  words,  the  fetus  passes  from  the  clean  to  the  relatively  clean, 
and  finally  to  the  unclean.  Moreover,  during  and  after  the  journey  of  the  fetus 
through  the  birth-canal  nature  has  provided  additional  safeguards  against 
infection,  notably  the  physiological  increase  of  the  vaginal  mucus,  which  while 
its  germicidal  power  has  doubtless  been  greatly  overestimated  may  at  least  be 
regarded  as  in  most  cases  unfavorable  to  the  multiplication  of  bacteria,  and 
which  attends  the  normal  progress  of  the  first  and  second  stages  of  labor;  the 
flushing  of  the  canal  from  within  outward  by  the  aseptic,  saline  liquor  amnii 
at  the  end  of  the  first  stage;  by  a  second  flushing  of  the  canal  by  a  rush  of  aseptic 
saline  blood  and  liquor  amnii  at  the  termination  of  the  second  stage ;  at  the 
termination  of  the  third  stage  the  cleansing  process  is  completed  by  the  out- 
ward passage  of  the  placental  mass  and  the  subsequent  flow  of  blood.  Then 
follow  quickly  the  reparative  processes  of  nature  to  close  the  open  blood-vessels 
and  lymphatics.  While,  as  we  thus  see,  all  nature's  processes  are  from  within 
outward  and  conservative, — from  the  sterile  toward  the  septic, — manipula- , 
tions  on  the  part  of  the  obstetrician  must  necessarily  be  from  without  inward — 
from  the  unclean  toward  the  clean.  It  is  also  probable  that  the  microorganisms 
of  the  external  genitals  have  an  intrinsic  tendency  to  migrate  to  the  vagina, 
and  to  invade  the  puerperal  uterus,  and  even  the  uterus  in  labor;  and  that  they 
are  able  to  prevail  at  times  even  in  the  face  of  the  conservative  forces  just 
enumerated.  Hence  the  importance  of  non-interference  except  in  the  presence 
of  a  positive  indication. 

Prophylaxis. — While  in  the  management  of  pregnancy  we  can,  as  a  rule, 
act  only  indirectlv  as  far  as  gynecological  prophylaxis  is  concerned,  we  can  in 
the  management  of  labor  do  a  great  deal  which  is  of  positive  and  immeasurable 
benefit  to  the  patient  in  preventing  subsequent  serious  and  perhaps  lifelong 
disability. 

Limiting  the  Duration  of  Labor. — That  a  labor  prolonged  beyond  the  limits 
of  safety  is  of  itself  the  cause  of  subsequent  local  trouble  is  well  known.  This 
statement  is  applicable  to  all  kinds  of  abnormal  labor,  but  finds  its  best  appli- 
cation in  cases  in  which  local  sloughing  of  the  maternal  parts  (leading  sometimes 
to  vesico-vaginal  fistula)  is  caused  by  prolonged  pressure  of  the  fetal  head.  Mater- 
nal lesions  may  be  the  result  not  only  of  the  premature  or  unskilful  use  of  the 
forceps,  but  also  of  undue  delay  in  its  use.  To  lay  down  exact  rules,  as  some 
have  attempted  to  do,  as  to  the  time  which  should  be  allowed  to  elapse  before 
the  application  of  the  forceps  without  reference  to  the  individual  case,  is  wrong. 
Many  other  circumstances  must  guide  us  here.  But  it  is  safe  to  say  that  when 
with  good  uterine  contractions  the  head  remains  stationary,  the  danger  of 
injury  to  the  maternal  soft  parts  becomes  an  important  factor.  A  similar 
danger  also  arises  from  too  prolonged  efforts  to  retard  the  passage  of  the  head 
through  the  vaginal  outlet  in  order  to  prevent  laceration  of  the  perineum. 
I  refer  here  not  only  to  the  dangers  arising  from  prolonged  pressure,  but  also 
to  permanent  relaxation  of  the  muscular  structures  of  the  pelvic  floor,  with 
resulting  disability. 

Prompt  Surgical  Treatment  of  Traumatism. — It  should  be  the  aim  of  the 
obstetrician  to  leave  his  patient  in  at  least  as  good  condition  as  that  in  which 
he  finds  her,  and  no  man  should  attempt  the  care  of  the  lying-in  patient  who 
does  not  understand  the  ultimate  results  of  the  more  common  lesions  of  the 
genital   tract    which    may  accompany   the   parturient    act,   and  the   methods 


THE   MANAGEMENT   OF   LABOR.  465 

of  their  repair.  Not  long  ago,  when  trachelorrhaphy  was  a  very  common 
operation,  and  when  the  importance  of  cervical  lacerations  with  reference  not 
only  to  the  etiology  of  cancer  but  of  various  lesser  troubles  was  overrated, 
the  immediate  suture  of  cervical  lacerations  was  advocated  in  many  quarters. 
With  the  advent  of  more  correct  views,  however,  the  majority  of  obstetricians 
do  not  favor  the  immediate  repair  of  cervical  lacerations  unless  required  by 
severe  hemorrhage.  The  danger  of  sepsis  is  by  no  means  inconsiderable. 
The  importance  of  the  immediate  repair  of  all  lacerations  which  endanger 
the  muscular  structure  of  the  pelvic  floor  is  now  generally  recognized. 

Asepsis. — Most  important  of  all  in  connection  with  prophylaxis  during  labor 
is  rigid  attention  to  asepsis  and  antisepsis.  The  importance  of  septic  infection 
as  a  factor  in  the  production  of  uterine  and  pelvic  disease  is  too  evident  to  need 
comment.  One  fact,  however,  I  desire  to  emphasize:  viz.,  that  what  is  called 
antiseptic  midwifery,  while  it  has  enormously  decreased  the  mortality  from 
puerperal  infection,  has  by  no  means  had  a  corresponding  effect  upon  the  mor- 
bidity. We  are  too  prone  to  consider  only  mortality  in  our  results  and  to 
pass  over  entirely  the  question  of  morbidity.  Even  to-day  the  influences  upon 
morbidity,  the  ultimate  consequences  of  a  mild  puerperal  process,  are  too 
apt  to  pass  unrecognized  by  the  obstetrician,  and  the  case  passes  into  the  hands 
of  the  gynecologist  for  the  cure  of  chronic  uterine  and  peri-uterine  inflammation, 
which  had  its  origin  in  an  unnecessary,  if  not  careless,  vaginal  examination. 
We  hear  much  of  a  lowered  mortality,  and  little  or  nothing  of  a  reduced  mor- 
bidity. 

Preliminary  Preparations. — (i)  The  obstetric  outfit.  (2)  Mother's  outfit. 
(3)  Baby's  outfit.  (4)  Physician's  obstetric  bag.  (5)  The  obstetric  nurse.  (6) 
The  lying-in  room.  (7)  The  labor  bed.  (8)  Articles  to  be  in  readiness  at  time 
of  labor. 

I.  The  Obstetric  Outfit. — Shall  the  obstetric  outfit  be  prepared  by  the 
patient  or  nurse,  or  shall  it  be  procured  already  prepared  from  some  dealer 
in  surgical  dressings?  A  further  question  naturally  suggests  itself — namely. 
Of  what  does  the  obstetric  outfit  to-day  consist?  Aside  from  the  mother's 
outfit,  meaning  the  clothes  she  will  need  during  her  lying-in  period,  and  the 
"baby's  outfit,"  including,  if  possible,  a  "baby's  basket,"  the  obstetric  outfit 
should  include  at  least  the  following  articles:  (i)  A  douche  pan,  preferably 
square  and  of  enamel  or  agate-ware.  (2)  Two  ordinary  rubber  blankets,  or 
two  pieces  of  rubber  sheeting,  one  one  yard  square  and  the  other  two  yards 
square.  (3)  Three  or  four  dozen  soft  napkins  for  vulval  dressings,  or  the  same 
number  of  vulval  pads  from  a  surgical-dressing  dealer.  (4)  One  or  two  pounds 
of  sterilized  absorbent  cotton,  or  twenty-five  yards  of  cheese-cloth  or  sterilized 
gauze,  for  sponging.  (5)  Six  abdominal  binders  of  soft  muslin  or  mull,  eighteen 
inches  wide  and  preferably  made  to  fit  the  figure  at  the  sixth  month  of  gestation. 
(6)  Two  hand-brushes.  (7)  Some  old  linen  for  the  baby's  eyes  and  mouth. 
(8)  Four  ounces  of  tincture  of  green  soap.  (9)  Bottle  of  sublimate  tablets. 
(10)  Seven  ounces  of  chloroform.  (11)  Four  ounces  of  boric  acid,  pow^dered. 
(12)  One  tube  of  sterile  white  vaseline  (for  the  baby).  (13)  Small  and  large 
safety-pins  and  bank-pins. 

If  there  is  no  nurse  available  before  labor  sets  in,  and  it  is  necessary  for  the  patient  to 
see  to  the  cleansing  of  the  above  articles,  she  may  be  instructed  to  pin  the  douche  pan,  rub- 
ber sheeting,  and  hand-brushes  separately  in  coarse  kitchen  towels  and  boil  them  for  half 
an  hour  in  an  ordinary  wash-boiler.  The  articles  so  boiled  are  then  dried  without  removing 
the  towels,  put  away,  and  not  opened  until  the  time  of  labor.  The  soft  napkins,  if  these  are 
to  be  used  for  vulval  dressings,  should,  freshly  laundered,  be  pinned,  half  a  dozen  in  a 
package,  in  coarse  kitchen  towels,  and  put  away  until  the  onset  of  labor.  The  nurse  is  then 
30 


466  PHYSIOLOGICAL  LABOR. 

instructed  to  sterilize  one  package  at  a  time  by  placing  it  in  the  oven  until  the  outer  covering 
is  scorched.  For  sterilizing  instruments  and  dressings  in  the  oven  of  the  kitchen  range,  one 
only  requires  a  thermometer  graduated  to  200°  C,  so  as  to  prevent  the  temperature  rising 
too  high,  and  to  make  sure  that  140°  C.  is  obtained.  The  absorbent  cotton,  the  old  linen 
for  the  baby's  eyes,  and  the  cheese-cloth  are  treated  in  the  same  way,  the  two  latter  being 
cut  up  into  convenient  pieces  and  sterilized  as  needed.  It  is  sufficient  that  the  abdominal 
binders  be  thoroughly  laundered  and  pinned  separately  in  freshly  laundered  towels  until 
needed.  It  will  be  noted  that  the  time-honored  douche  bag  and  tube  have  not  been  referred 
to,  and  this  is  because  I  do  not  employ  douches  except  for  positive  indication;  and,  further, 
because  I  believe  these  articles  should  be  part  of  the  physician's  outfit,  sterilized  and  cared 
for  under  his  direct  supervision. 

Most  or  all  of  the  articles  contained  in  the  above  list  of  the  "  obstetric  outfit  "  can  to-day 
be  obtained,  sterilized  in  their  final  wrappers  and  ready  for  use,  from  many  of  the  dealers 
in  surgical  dressings  (notably.  Van  Horn  &  Co.,  New  York;  Kalish,  New  York;  Johnson  & 
Johnson,  New  York;  Fraser  &  Co.,  New  York),  at  prices  for  the  outfit  varying  from  four 
to  thirty  dollars.  These  obstetric  outfits,  cleansed  and  sterilized,  are  usually  packed  and 
sealed  in  a  neat  box,  thus  allowing  the  contents  to  be  kept  intact  until  needed.  The  con- 
tents of  these  outfits  vary  somewhat  in  detail,  but  the  following  list  contains  the  essentials: 
(i)  Agate-ware  (square)  douche  pan.  (2)  Sterilized  bed  pads.  (3)  Sterilized  vulval 
pads.  (4)  Sterilized  absorbent  cotton.  (5)  Sterilized  absorbent  gauze.  (6)  Two  pieces 
of  rubber  sheeting  or  two  ordinary  rubber  lalankets,  one  for  permanent  labor  bed  and  the 
second  for  the  draw-sheet.  (7)  Abdominal  binders.  (8)  Glass  and  rubber  catheters,  {g) 
Scrub-  and  hand-brushes.  (10)  Sterilized  tape  for  cord.  (11)  Sublimate  tablets;  boric 
acid  powdered;  chloroform;  ergot;  borated  talcum  powder;  soap;  tube  of  sterile  vase- 
line; safety-pins. 

2.  Mother's  Outfit. — -(i)  A  number  of  merino  or  flannel  undervests  to  be  changed  night 
and  morning,  to  secure  free  skin  action  and  prevent  chilling.  (2)  Long  night-dresses  to  be 
changed  once  a  day.  (3)  Warm  flannel  wrap  or  dressing  sacque.  (4)  Abdominal  binders 
of  soft  muslin,  half  a  yard  wide  and  made  to  fit  the  figure  at  the  sixth  month  of  gestation. 
(5)  Breast  binders  for  large  and  pendulous  breasts,  plain  muslin  or  ordinary  corset-covers 
(see  Part  VI) .     An  abundance  of  old  linen  sheets  and  a  generous  supply  of  towels. 

3.  Baby's  Outfit. — Should  be  plain,  so  as  to  withstand  frequent  washing;  with  long 
sleeves  and  high  neck  to  secure  warmth,  since  cold  is  so  injurious  to  the  newly  bom,  and 
loose  and  light  in  weight,  so  as  not  to  impede  any  organ  in  the  body,  (i)  Soft  flannel  under- 
shirts with  high  neck  and  long  sleeves,  open  in  front  so  as  to  be  easily  removed  or  adjusted. 

(2)  Four-inch,  soft  flannel  binders  to  go  round  the  abdomen  and  lap  one-third,  which  should 
not  be  hemraed  but  overstitched,  and  should  be  secured  to  the  child  with  tapes  or  sewed. 

(3)  Cotton  or  linen  diapers,  which  should  not  be  of  canton-flannel.  When  folded  once,  the 
diaper  is  half  a  yard  square  (to  fasten  with  safety-pins).  A  second  napkin  is  sometimes 
necessary.  (4)  Heavy  or  light,  according  to  season,  flannel  slip  to  act  as  bath  petticoat 
and  dress,  open  and  fastened  in  front.  (5)  Knit  woolen  socks  reaching  nearly  to  the  knee. 
Cold  feet  are  often  an  exciting  cause  of  colic.  White  muslin  slip  may,  if  desired,  be  worn 
over  flannel  slip.  When  there  is  little  hair  on  the  head,  a  plain  cambric  or  light  flannel  cap 
will  prevent  nasal  catarrh.  Bahy  basket:  The  ordinary  contents  are:  (i)  Bobbin.  (2) 
Scissors.  (3)  Safety-pins.  (4)  Soft  linen  (4^  by  4)  in  boracic  acid  solution  for  cleansing 
cord,  eyes,  and  mouth.  (5)  Soft  hair-brush.  (6)  Powder  box  of  lycopodium  or  fine  starch 
powder.  (7)  Tube  of  sterilized  white  vaseline.  (8)  Soft  towels.  (9)  Complete  change  of 
clothing.      (10)   Woolen  shawl,  blanket,  or  wrap. 

4.  The  Physician's  Obstetric  Bag. — For  several  years  I  have  experi- 
mented with  different  patterns  of  bags  and  cases  in  order  to  fulfil  the 
requirements  of  private  practice.  I  have  always  looked  on  leather  obstetric 
bags  with  suspicion  and  fear,  because  of  the  difficulty  of  cleansing  them,  and 
because  articles  to  be  used  in  the  lying-in  room  cannot  be  safely  carried  in 
them  unless  such  articles  and  instruments  are  boiled  immediately  before  use; 
further,  I  believe  that  the  ordinary  obstetric  leather  bag  which  has  been  from 
one  case  to  another,  in  cabs  and  street-cars,  which  of  necessity  has  had  its 
interior  soiled  by  bloody  fingers  and  instruments,  green  soap,  ergot,  or  other 
drugs,  has  no  place  in  the  lying-in  room  in  the  present  age  of  aseptic  surgery. 
Leather  obstetric  bags  can,  therefore,  not  be  recommended,  because  of  the 
difficulty,  if  not  impossibility,  of  cleansing  them.  Linen  obstetric  bags  which 
can  be  boiled  or  sterilized  by  steam  have  been  used  in  Germany.  Diihrssen 
has  an  asbestos  bag  which  can  be  sterilized  by  dry  heat  with  the  instruments 
in  situ.  Aluminium  I  have  found  unsuitable  by  reason  of  the  uncertain  com- 
position of  the  metal.     The  ideal  obstetric  case  is  one  made  entirely  of  metal 


THE  MANAGEMENT  OF   LABOR.  467 

which  will  permit  of  cleansing  by  dry  heat,  steam,  or  boiling.  Such  a  case 
'  may  be  contained  for  transportation  in  a  suitable  holder  or  bag.  The  bag- 
shaped  cover  is  preferable  because  more  convenient  and  conventional.  The 
great  disadvantage  of  a  metal  case,  aside  from  its  greater  cost,  is  its  additional 
weight.  The  aseptic  metal  obstetric  case,  which  is  here  recommended,  is  the 
result  of  much  experimenting,  and  weighs  but  six  pounds  more,  including 
leather  holder,  than  an  ordinary  leather  obstetric  bag.  The  weight  of  the 
case  complete  with  glassware  filled,  and  including  a  Tarnier  forceps,  is  twenty- 
five  pounds.  This  increased  weight  can  be  further  reduced  some  two  pounds 
by  the  use  of  lighter  metal  in  the  manufacture  of  the  case.  From  actual  expe- 
rience extending  over  a  period  of  several  years  I  believe  that  the  inconvenience 
of  the  additional  five  or  six  pounds  is  more  than  overbalanced  by  the  many 
advantages  of  such  a  case,  not  the  least  of  which  is  cleanliness. 

The  case  practically  consists  of  two  trays,  male  and  female,  made  of  sheet-iron  and 
enameled  in  white  at  a  temperature  of  several  hundred  degrees  (Fig.  609).  The  male  or 
larger  tray  measures  17X8X6  inches,  partially  fits  into  a  shallower  female  tray  (17  X  8 
X  si  inches),  leaving  a  space  of  two  inches,  in  which  space  is  contained  a  third  tray 
made  of  canvas,  with  loops  and  compartments  to  contain  the  glassware  of  the  case.  A 
leather  holder  or  case  covers  both  trays  when  fitted  together,  and  strong  straps  hold  all 
firmly  together.  My  objects  in  having  the  case  thus  made  of  two  trays,  one  large  and  the 
other  small,  and  both  enameled  at  a  high  temperature,  with  an  inner  canvas  tray  to  contain 
the  glassware,  are  as  follows: 

1.  The  case  is  aseptic.  The  case  proper  can  always  be  rendered  sterile  before  being 
taken  to  a  confinement  by  boiling,  by  baking  in  an  ordinary  kitchen  oven,  or  by  steam 
under  pressure,  as  the  size  of  the  case  permits  its  being  sterilized  in  the  medium-sized  steam 
sterilizer  of  the  market.  No  matter  what  the  character  of  the  complication  attended,  be  it 
ever  so  septic,  or  instruments,  douche  bag,  catheter,  gown,  etc.,  ever  so  soiled  with  pus  or 
blood  when  thrown  into  the  case  to  be  carried  away,  the  entire  outfit  can  be  placed  in  a 
wash-boiler  and  rendered  sterile  in  a  short  period  of  time  by  boiling. 

2.  Such  a  case  furnishes  us  at  the  bedside,  after  the  canvas  tray  is  removed  from  the 
smaller  tray  and  the  contents  from  the  larger,  with  two  sterile  receptacles  which  may  be  put 
to  a  number  of  uses  and  will  often  prove  most  valuable  and  convenient.  For  example: 
aside  from  a  supply  of  hot  water  in  an  emergency,  nothing  more  need  be  required  to  conduct 
a  confinement  than  the  case  and  its  contents;  as  the  larger  tray,  which  holds,  when  half- 
full,  six  quarts,  may  be  used  to  wash  the  hands  and  forearms  in  soap  and  water,  and  the 
smaller  female  tray,  which  holds,  when  half- full,  three  quarts,  to  disinfect  the  hand  and 
forearm  in  sublimate  solution. 

3.  The  length  of  this  tray  (seventeen  inches)  permits  of  the  entire  forearm  being  sub- 
merged in  the  sublimate  solution,  an  advantage  that  will  quickly  be  appreciated  by  the 
surgeon  (Fig.  609). 

4.  I  am  in  the  habit  of  using  the  smaller,  female  tray  as  a  sterilizer.  When  in  the 
course  of  labor  indications  point  to  the  use  of  forceps,  the  instrument,  still  secured  in  its 
labeled  canvas  case,  is  placed  in  the  smaller  tray  of  the  case  and  sent  to  the  kitchen  to  be 
boiled  for  an  hour.  The  boiling  water  is  poured  off  in  the  kitchen,  and,  the  forceps  still  in 
its  case,  is  brought  in  the  tray  to  the  bedside,  and  the  case  is  opened  only  after  the  patient 
and  the  operator's  hands  have  been  prepared  for  operation. 

5.  The  larger  tray,  again,  by  reason  of  its  size,  makes  an  excellent  bath  in  which  to 
plunge  an  asphyxiated  child,  and  one  has  always  at  hand  a  convenient  bath-tub  in  which  a 
modified  Byrd's  method  of  artificial  respiration  can  be  carried  on,  the  child  being  meanwhile 
submerged  in  very  hot  water  (Fig.  609) . 

6.  The  advantages  of  the  inner  canvas  tray,  which  rests  in  the  space  between  the 
two  metal  trays,  will  be  readily  appreciated.  This  tray  is  practically  a  canvas  case 
measuring  17X8X2  inches,  with  a  lid,  and  canvas  handles  at  either  end  to  lift  it  out  of  the 
smaller  metal  tray  (Fig.  609).  My  object  in  using  canvas  here,  with  a  separate  loop  or 
compartment  for  each  piece  of  glassware  or  instrument,  was  to  secure  a  noiseless  tray  for 
this  part  of  the  physician's  obstetric  outfit,  one  in  which  the  articles  are  all  in  plain  sight, 
so  as  to  be  selected  at  an  instant's  notice,  and  one,  moreover,  that  can  be  repeatedly  cleansed 
by  boiling  whenever  soiled  by  bloody  fingers,  soap,  vaseline,  or  ergot. 

7.  The  case  as  a  whole  is  readily  converted  into  an  obstetric  operating  case  by  the 
addition  of  the  desired  instruments  pinned  in  towels  and  placed  in  the  larger  of  the  two 
trays,  for  which  purpose  sufficient  room  has  been  provided.  The  length  of  the  large  tray 
permits  of  Tamier's  forceps,  a  cranioclast,  and  a  cephalotribe  being  carried  in  it. 

Contents  of  the  Case. — (a)  In  large  male  tray:  (i)  Clean  apron.  (2)  Kelly  pad.  (3) 
Canvas  lithotomy  sling.  (4)  Four-quart  sterile  douche  bag  in  canvas  case.  (5)  MetaJ 
receptacle  containing  sterile  vaginal  and  douche  tubes  and  glass  catheter.      (6)   Volsella, 


Fig.    609. — The   Author's   Obstetric   Case. —  (From   a   photograph.) 

468 


THE  MANAGEMENT   OF  LABOR.  469 

dressing,  needle  and  tongue  forceps,  and  scissors  in  canvas  case.  (7)  Obstetric  forceps  in 
canvas  case.  (8)  Sterile  cotton  and  plain  gauze.  (9)  Five  per  cent,  iodoform  gauze.  (10) 
Two  sterile  nail-brushes.    -(11)    Rubber  gloves. 

The  two  metal  and  the  one  canvas  tray  having  been  cleansed  by  boiling  or  by  dry 
or  moist  heat,  as  already  described,  each  of  the  various  articles  contained  in  the  above 
list  is  cleansed  in  a  different  manner  in  order  to  secure  surgical  cleanliness,  (i)  The 
apron  or  canvas  suit  is  simply  freshly  laundered.  (2)  The  Kelly  pad  is  cleansed  with  laun- 
dry soap,  hot  water  and  a  brush,  and  finally  with  a  i  :  20  carbolic  acid  solution;  shoiold  the 
pad  be  used  about  a  case  in  which  a  suspicion  of  sepsis  exists,  it  is  boiled  for  half  an  hour. 
(3)  The  Kelly  canvas  lithotomy  sling  is  made  of  canvas,  galvanized  iron  rings,  and  brass 
buckles,  and  is  boiled  for  half  an  hour  after  use.  (4)  The  four-quart  douche  bag  and  tubing 
are,  after  use,  scrubbed  with  hot  water,  soap,  and  a  brush,  rinsed  in  clean  hot  water,  placed 
in  its  canvas  case,  and  boiled  for  half  an  hour.  The  towel  and  bags  are  then  allowed  to  dry 
in  an  enamel-ware  vessel  over  the  kitchen  range,  and  when  dry  are  placed  in  the  case.  (5) 
The  metal  receptacle  containing  the  glass  douche  tubes  and  catheter  is  boiled  together  with 
the  lithotomy  sling  and  douche  bag.  Both  metal  receptacle  and  glass  tubes  are  first,  how- 
ever, scrubbed  in  a  hot  soda  solution  with  soap  and  a  brush.  (6)  The  volsella,  dressing, 
needle  and  tongue  forceps,  and  scissors  are,  before  being  placed  in  the  canvas  case,  simply 
scrubbed  in  hot  soda  solution  with  soap  and  a  brush  and  then  dried,  as  they  are  intended  to 
be  sterilized  at  the  residence  of  the  patient.  (7)  The  obstetric  forceps  is  treated  in  the  same 
manner  as  the  foregoing.  (8)  The  sterile  cotton,  plain  gauze,  and  iodoform  gauze  can  be 
procured  already  sterilized  from  a  dealer  in  surgical  dressings. 

(6)  In  the  canvas  tray  contained  in  the  small  female  tray  are:  (i)  Green  soap  (sterile). 
(2)  Vaseline  (sterile).  (3)  Gauze  eye  sponges  (sterile).  (4)  Gauze  cord  dressing  (sterile). 
(5)  Chloroform.  (6)  Ergot.  (7)  Strong  acetic  acid  (99.5  per  cent.).  (8)  Sublimate 
tablets.  (9)  Fine  boric  acid  (sterile).  (10)  Normal  saline  powders.  (11)  Silver  nitrate 
solution  (2  per  cent.).  (12)  Tape  for  cord  (sterile).  (13)  Silk  and  gut  ligatures  and 
needles  (sterile).  (14)  Soft-rubber  catheter  (sterile).  (15)  Umbilical  scissors.  (16) 
Medicine-dropper.  (17)  Nail-cleaner.  (18)  Safety  razor.  (19)  English  catheter  (No, 
16)  with  stylet.  (20)  Safety-pins.  (21)  Sterile  gauze  bandage  for  sling.  (22)  No.  8 
soft  braided  catheter  opening  at  end.      (23)    Spring  scales. 

Obstetric  Operating  Case. — For  an  operating  set,  add  to  the  labor  case  the  following:  (i) 
Braun's  cranioclast.  (2)  Dubois's  scissors.  (3)  Smellie's  perforator.  (4)  Three  artery 
clamps.  (5)  Perineal  retractor.  (6)  Tamier  forceps.  The  above  six  in  canvas  cases.  (7) 
Scalpel  and  blunt  bistouuy.  (8)  Ether.  (9)  Rubber  apron.  (10)  Sterile  gauze  bandages 
for  slings. 

Use  oj  the  Case  at  the  Bedside.* — It  is  recommended  in  the  use  of  this  obstetric 
case  at  the  bedside  that  the  leather  cover  be  removed  in  another  room  or  the 
hall,  and  only  the  enamel-ware  trays  carried  into  the  lying-in  room.  A  small 
table  is  selected,  placed  at  the  head  of  the  bed  on  the  side  selected  for  vaginal 
examination  and  delivery.  This  table  is  covered  with  two  or  three  freshly 
laundered  towels.  The  large  male  case  is  lifted  out  of  the  smaller  female 
tray  and  placed,  with  its  contents  undisturbed,  at  the  distal  end  of  the  table 
(Fig.  610).  The  canvas  tray  is  then  lifted  out  of  the  small  female  tray  and 
placed,  with  its  lid  thrown  back,  next  to  the  large  tray,  and  lastly  and  nearest 
the  physician  is  placed  the  small  female  tray  ready  for  the  sublimate  solution. 
If  it  is  desirable  to  use  the  larger  tray  for  hand  washing,  the  articles  contained 
in  it  may  be  arranged  conveniently  upon  another  portion  of  the  table.  Ordi- 
narily I  do  not  disturb  the  contents  of  the  larger  tray  until  needed,  and  use 
running  tap-water  for  hand  cleansing  with  soap  and  water. 

The  nail-cleaner,  green  soap,  and  one  of  the  hand-brushes  are  now  taken  to 
the  nearest  tap  of  hot  and  cold  water  or  to  a  basin  of  hot  water,  the  coat  is  re- 
moved, the  sleeves  are  rolled  to  the  elbow,  the  nails  are  cleaned,  and  the  hands 
and  forearms  are  scrubbed  and  rinsed  free  of  soap.  Returning  to  the  bedside, 
the  clean  gown  is  put  on,  the  remaining  hand-brush  is  dropped  into  a  solution  of 
I  :  2000  sublimate  in  the  smaller  tray,  and  the  hands  and  forearms  are  scrubbed 
in  this.  Sterile  rubber  gloves  are  now  drawn  on.  The  patient  having  been  pre- 
pared for  vaginal  examination  and  confinement,  these  are  carried  out  forthwith. 
As  labor  goes  on,  the  various  articles  are  taken  from  the  canvas  and  large  tray  as 

*  My  obstetric  case  is  made  for  me  by  the  Kny-Scheerer  Co.,  225  Fourth  Avenue,  New 
York. 


470 


PHYSIOLOGICAL  LABOR. 


TOP    OF 


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STAND 


needed.  Sterile  cotton  and  plain  gauze  are  at  hand  as  needed  for  sponges  in  any 
of  the  three  stages ;  the  Kelly  pad  for  the  rupture  of  the  membranes  or  the  second 
and  third  stages,  or  vaginal  douches;  the  sterile  douche  bag  and  glass  tubes  for 
irrigation;  the  sterile  vaseline  for  lubricating  the  fingers,  if  one  desires  to  use  it; 
chloroform  for  administration  in  the  second  stage ;  sterile  gauze  sponges  to  wipe 
the  baby's  eyes  and  mouth  on  the  expulsion  of  the  head;  sterile  tape  to  tie  the 
cord;  sterile  dressing  for  the  same;  clean  scissors  to  cut  the  same;  nitrate  of  silver 
for  the  eyes;  ergot  for  the  end  of  the  third  stage  or  hemorrhage,  as  well  as  acetic 
acid  for  the  latter,  and  a  soft  catheter  to  aspirate  the  baby's  larynx.  Should 
complications  occur,  we  have  the  sterile  lithotomy  sling  and  the  Kelly  pad  for 

drainage  at  the  side  of  the 
bed ;  a  safety  razor  to  shave 
the  vulva;  a  catheter  to 
empty  the  bladder;  a  vol- 
sella  and  dressing  forceps 
and  iodoform  gauze  to 
pack  the  uterus;  needle 
forceps,  needles,  scissors, 
silkworm-gut  and  catgut 
for  lacerations  of  cervix  or 
perineum;  an  English  cath- 
eter to  replace  a  prolapsed 
cord ;  a  tube  to  give  intra- 
uterine irrigations,  and 
sterile  bandages  to  use  as 
slings  for  versions. 

If  major  obstetric  op- 
erations are  demanded,  we 
add  to  the  above  case  the 
list  of  instruments  already 
enumerated.  If  at  any  time 
in  the  course  of  labor  the 
forceps,  perineorrhaphy,  or 
uterine  packing  set  appears 
indicated,  it  is,  in  its  orig- 
inal wrappings,  placed  in 
either  the  larger  or  smaller 
tray  and  sent  to  the  kitchen 
to  be  baked  or  boiled. 

5.  The  Obstetric 
Nurse.  —  She  should  be 
free  from  cutaneous,  suppurative  disease  or  purulent  coryza,  nor  should  she  re- 
cently have  attended  cases  of  infectious  diseases,  especially  erysipelas,  scarlatina, 
diphtheria,  or  typhoid.  Oral  sepsis  on  the  part  of  the  obstetric  nurse  has  hereto- 
fore received  no  attention,  and  may  possibly  account  for  otherwise  inexplicable 
cases  of  puerperal  infection.  Two  nurses,  one  for  the  mother  and  one  for  the 
infant,  for  at  least  the  confinement  and  the  first  week  of  the  puerperium,  will 
generally  secure  a  smoother  and  more  rapid  convalescence,  and  are  strongly  to  be 
recommended.  The  obstetric  nurse  should  early  in  the  case  learn  the  attending 
obstetrician's  routine  management  of  mother  and  infant,  and  should  not  depart 
from  it  unless  serious  emergency  demand  it.  An  excellent  plan  is  for  the 
physician  to  provide  a  printed  resum^  of  his  general  treatment  of  the  pregnant, 


Fig.  610.- 


-Plan  showing  Arrangement    of  Lying-in 
Room. 


THE  MANAGEMENT   OF   LABOR. 


471 


parturient,  and  puerperal  woman,  and  have  the  nurse  familiarize  herself  with 
the  same. 

6.  The  Lying-in  Room. — The  lying-in  room  should  not  have  been  used 
by  any  one  suffering  from  infectious  disease,  and  it  should  be  of  good 
size,  well  ventilated,  and  with  as  much  sunlight  as  possible.  Care  should  be 
taken  as  to  the  plumbing  of  the  house,  and  the  room  should  be  as  far  removed 
from  drains  and  water-closets  as  possible.  It  should  be  thoroughly  cleaned  and 
all  unnecessary  draperies  and  upholstered  furniture  removed.  The  tempera- 
ture should  range  from  66°  to  72°  F.  A  bare  floor  is  preferred  to  a  carpeted  one, 
but  in  case  of  the  latter,  the  carpet  may  be  protected  by  an  oil-cloth  or  a  rug 
at  the  side  of  the  bed. 

7.  The  Labor  Bed. — The  bed  and  bedding  should  be  perfectly  clean. 
The  bed  should  be  accessible  from  both  sides  and  out  of  all  draughts.  It  should 
not  be  too  low.  Soft  beds  should  be  avoided,  a  hair  mattress  being  preferable. 
In  all  cases  requiring  operative  interference  it  is  much  better  to  deliver  the 
patient  upon  a  table.  Over  the  middle  third  of  the  mattress  a  piece  of  rubber 
sheeting,  oil-cloth,  or  tarred  paper,  a  yard  or  more  in  breadth,  is  placed  and 
pinned  firmly  with  safety-pins.  A  clean  bed-sheet  is  then  placed  over  the 
entire  mattress  and  pinned  down      This  is  the  permanent  bed  (Fig.  611).     Over 


PERMANENT  LABOR  BED{^SBBER''aHEETiKG' 

Fig.  611. — Plan  of  Arrangement  of  the  Permanent  and  the  Temporary  Labor 

Beds. 


the  site  of  the  permanent  rubber  sheeting,  a  second  rubber  sheet  of  the  same 
size  is  placed.  This  is  the  foundation  of  the  temporary  bed,  and  is  of  the  nature 
of  a  draw-sheet  (Fig.  611).  Upon  this  second  rubber  sheet  may  be  placed  one  of 
the  absorbent  obstetric  pads  now  commonly  sold,  or  several  sheets  folded  to  retain 
the  discharges  from  the  vagina.  During  labor  the  absorbent  pad  may  be  renewed 
as  necessary,  and  the  last  one,  together  with  the  upper  rubber  sheet,  ma}^  be  re- 
moved at  the  completion  of  labor.  The  permanent  rubber  sheeting  remains  for 
several  days  of  the  puerperium,  to  protect  the  mattress.  A  piece  of  oil-cloth  or 
waxed  cloth  or  a  freshly  laundei-ed  bath  blanket  should  be  placed  at  the  bedside 
to  protect  the  floor. 

8.  Articles  to  be  in  Readiness  at  Time  of  Labor. — (Obtainable  in  every 
household.)  (i)  Arrangement  for  an  abundant  supply  of  hot  water.  (2)  A  bowl 
for  vomited  matter.  (3)  Two  clean  earthen-,  agate-,  enamel,-  or  paper- ware 
bowls  for  hand  cleansing.  (4)  A  clean  bowl  for  the  placenta.  (5)  Three 
pitchers:  one  for  boiling  water,  one  for  cold  boiled  water,  and  one  for  mixing 
antiseptic  solutions.  (6)  A  clean  cup  or  tumbler  with  boric  acid  solution  and 
gauze  or  old  linen  wipes  for  the  baby's  eyes.  (7)  A  half-dozen  freshly  laundered 
old  linen  sheets  to  serve  as  bed  pads  or  pilches.  (8)  An  abundant  supply  of  freshly 
laundered  sheets  and  towels.      (9)  A  change  of  night-clothing,  warmed,  for  the 


472 


PHYSIOLOGICAL  LABOR. 


mother.     (lo)  A  warm  blanket  to  receive  the  baby.     Of  these  articles,  the  four 

bowls,  the  cup,  and  the  three  pitchers  should  be  scrubbed  with  soap  and  water 

and  boiled  in  a  wash-boiler  or  at  least  scalded  out.     It  is 

j sufficient  that  the  old  sheets  to  be  used  as  bed  pads  and  the 

usual  bed-sheets  and  towels  be  freshly  laundered.  For  special 
cases,  however, — for  example,  breech  presentations, — it  is 
desirable  that  half  a  dozen  towels  are  sterilized  by  boiling  or 
by  dry  heat  in  an  oven,  as  described  above. 

Response  to  Summons. — A  physician  engaged  to  attend 
a  case  of  confinement  should,  when  summoned,  respond  as 
promptly  as  possible,  since  by  the  rigid  observation  of  this 
rule  it  is  frequently  the  case  that  complications  which  may 
easily  be  remedied  at  an  early  stage  may  present  the  gravest 
difficulties  if  not  treated  till  a  later  period.  Examples  are 
malpresentation,  malposition,  faulty  attitude,  prolapse  of  the 
small  parts,  severe  perineal  laceration,  postpartum  hemor- 
rhage, and  fetal  asphyxia. 

Preparation  of  the  Physician. — (See  Asepsis  in  Obstetrics, 
page  148.) 

Preparation  of  the  Patient. — The  pubic  hair,  especially 
when  long  or  thick,  should  be  clipped  moderately  short  ;  then, 
whether  the  bowels  have  recently  moved  spontaneously  or 
not,  a  full  enema  of  soapsuds  (Oij)  and  glycerin  (one  ounce) 
should  be  administered.  After  the  onset  of  labor  the  use  of 
the  toilet  by  the  patient  should  be  forbidden  in  order  to 
lessen  the  dangers  of  infection,  and  the  commode  or  vessel 
must  then  be  substituted.  At  this  time  and  subsequently 
the  patient  should  be  encouraged  to  empty  the  bladder 
frequently  and  completely. 

The  Ante-partum  Bath. — The  traditional  ante-partum 
tub  bath  has  recently  *  been  the  subject  of  severe  criticism 
from  the  standpoint  of  asepsis.  Not  only  is  the  parturient 
woman  at  the  end  of  such  a  bath  immersed  in  a  dilution  of 
her  own  dirt,  but,  as  has  been  shown  experiinentally,  the  in- 
fected  water  often  enters  the 

vagina  of  both  primiparas  and  

multiparae.  Moreover,  under 
such  conditions  the  danger  of 
nipple  infection  is  always  pre- 
sent. The  ideal  ante-partum 
bath,  then,  would  be  for  the  patient  to  stand  or  sit 
under  a  running  stream  of  boiled  water,  thus  elimin- 
^.ting  another  possible  source  of  septic  infection  of 
the  parturient  woman.  This  can,  in  maternity 
hospitals,  readily  be  accomplished  under  a  warm 
shower-bath  and  in  some  dwellings  in  private  prac- 
tice. When  a  shower  of  boiled  water  is  not  available, 

the  author  instructs  the  nurse  to  place  the  patient  in  a  bath-tub  and  to 
pour  several  gallons  of  boiled  water,  allowed  to  cool  to  the  proper  temperature, 
over  the  shoulders  of  the  patient,  the  patient  at  the  same  time  being  instructed 


Fig.  612. — White 
Linen  Suit 
FOR  Obstetric 
Work. 


SIKPJLE 

OBSTETRIC  or-T:RATfXG  SUIT 

IN  LINEN  CASE 


Fig.  613. — Case  Containing 
Linen  Suit  for  Obstetric 
Work. 


*  Sticher:  "  Centralblatt  f.  Gjmakologie,"  Mar. 
Gynakologie,"  Feb.  9,  1901. 


2,  1901;  and  Strogan:  "Centralblatt  f. 


THE   MANAGEMENT   OF   LABOR.  473 

thoroughly  to  scrub  the  external  genitals  and  body  generally  with  a  coarse,  clean 
wash-cloth  and  green  soap,  the  nurse  using  the  soap  on  the  back  and  shoulders. 
All  soap  is  finally  washed  off  and  the  bath  completed  with  several  quarts  of 
sublimate  solution  (i  :  5000*).  The  patient's  external  genitals  are  finally 
thoroughly  cleansed  by  the  nurse  with  absorbent  cotton  and  a  i  :  2000  solution 
of  sublimate.  The  surface  of  the  body  is  now  dried  with  brisk  friction.  A 
sterile  vulval  pad  as  a  temporary  occlusion  dressing  is  then  applied  and  pinned 
to  a  waist-band  made  from  a  clean  gauze  bandage  (Fig.  633).  If  a  bath-tub 
is  not  available,  the  following  procedure  is  recommended:  (i)  Have  the  patient 
take  a  sponge-bath  of  hot  water  and  soap,  using  not  a  sponge  but  a  clean  wash- 
cloth. (2)  The  nurse  is  instructed  to  cut  the  pubic  hair  short,  if  it  is  long  or 
thick,  with  scissors.  (3)  The  nurse  now  with  a  soft  hand-brush  or  absorbent 
cotton  scrubs  with  soap  and  hot  water  the  external  genitals,  pubes.  and  inner 
sides  of  the  thighs,  and  cleanses  the  vulval  canal  from  above  downward  with 
absorbent  cotton  and  soap  and  water.  (4)  The  parts  are  now  rinsed  off  with 
clean  water.  (5)  The  same  parts  are  then  with  absorbent  cotton  and  i  :  2000 
sublimate  solution  given  a  final  cleansing,  always  toward  the  anus,  care  being 
taken  to  include  the  vulval  canal  with  the  sublimate  solution.  A  sterile  vulval 
pad  or  gauze  is  now  applied  to  the  external  genitals  as  a  temporary  occlusion 
dressing,  and  fastened  by  a  T-bandage.  In  every  method  of  cleansing  the 
vulval  canal  and  external  genitals  the  greatest  care  must  be  used  to  avoid 
the  production  of  erosions  by  stiff  brushes  or  rough  handling,  as  these  lesions 
may  subsequently  become  infected. 

Ante-partum  Vaginal  Irrigation. — It  now  appears  that  the  consensus  of 
opinion  of  a  few  years  ago  as  to  the  sterility  and  germicidal  qualities  of  the  vaginal 
mucus  was  somewhat  premature.  It  is  certain  that  the  vagina  in  the  healthy 
pregnant  woman  very  often  contains  bacteria,  often  streptococci,  and  that  in  a 
majority  of  cases  the  germs  enter  the  uterus  immediately  after  delivery. 

It  is  nowhere  maintained  that  this  phenomenon  is  inherently  pathological ;  but 
it  cannot  be  doubted  that  sometimes  this  is  the  case,  and  it  is  more  than  likely 
that  these  bacteria  are  responsible  for  the  residual  morbidity  with  occasional 
death  which  cannot  be  made  to  vanish  with  the  strictest  asepsis.  This  source  of 
morbidity,  if  reached  at  all,  may  be  reached  only  with  ante-partum  antisepsis. 

The  Examination  of  Labor. — The  Obstetric  Examination. — On  enter- 
ing the  lying-in  chamber  the  physician  should  note  in  a  general  way  the  physical 
and  mental  condition  of  the  patient,  and  should  she  be,  as  is  naturally  in  most 
instances  the  case,  the  victim  of  anxiety  and  nervousness,  he  should  endeavor 
by  his  words  and  demeanor  to  reassure  her  and  to  quiet  her  apprehension.  He 
should  then  take  the  pulse  and  temperature,  not  forgetting  that  the  former 
is  often  increased  by  nervous  influences,  and,  if  time  permits,  a  brief  but  careful 
examination  of  the  heart  and  lungs  is  advisable,  if  this  has  not  already  been 
attended  to  (see  page  148).  In  the  obstetric  examination  it  is  advisable  for 
the  physician  to  follow  some  routine  in  order  to  avoid  needless  repetition  and 
to  secure  thoroughness,  (i)  The  patient  has  been  prepared  for  labor  as  de- 
scribed on  page  472.  She  is  placed  on  a  couch  or  bed  in  the  dorsal  posture, 
with  the  head  but  slightly  raised,  clothed  only  in  her  night-dress  and  covered  by  a 
sheet.  (2)  Unless  such  information  has  already  been  obtained  at  the  exami- 
nation during  pregnancy,  it  is  well  at  this  point  to  record  the  age,  parity, 
former  health,  especially    children's    diseases   of   the    individual    and  at   what 

*  Statistical  proof  from  the  Imperial  Maternity  Asylum  of  St.  Petersburg  shows  a  fall 
of  7.4  per  cent,  in  fever  in  the  puerperal  woman  by  the  substitution  of  the  shower  for  the 
old-fashioned  tub  bath. 


474  PHYSIOLOGICAL  LABOR. 

age  she  first  walked;  the  type  and  date  of  her  last  menstruation;  the  history 
of  her  present  pregnancy,  and  the  character  of  her  former  pregnancies,  labors, 
and  puerperiums.  The  patient  should  be  exposed  as  little  as  possible,  hence 
for  the  external  examination  two  sheets  may  be  used,  one  to  cover  the  body 
and  one  the  lower  extremities  from  the  pubes  down,  the  upper  sheet  being 
raised  to  expose  the  abdomen  (Fig.  194).  For  the  external  examination  in  the 
dorsal  posture,  the  patient  may  be  covered  with  a  sheet,  as  shown  in  Fig.  194. 
(4)  The  physician  renders  aseptic  his  hands  and  forearms  as  described  on  page 
150,  not  forgetting  that  his  coat  should  be  removed  and  his  forearm  bared 
to  the  elbow.  The  woman  physician  should  see  to  it  that  her  sleeves  are  made 
so  as  to  allow  of  their  being  rolled  up.  The  use  of  sterile  rubber  gloves  is  to- 
day the  best  means  for  the  prevention  of  infection. 

External  Examination. — Having  attended  to  the  foregoing  prelimin- 
aries, it  is  now  in  order  to  make  the  external  examination,  and  this  should 
always,  except  in  case  of  emergency,  precede  the  internal,  because:  (i)  It 
enables  one  to  make  the  latter  more  intelligently;  and  (2)  it  helps  one  to  gain 
the  confidence  of  the  patient  and  prepare  her  for  the  internal  examination. 
This  part  of  the  examination,  often  neglected  and  usually  undervalued,  is 
of  the  highest  importance.  By  many  authorities  it  is  considered  almost  equal 
in  value  to  vaginal  examination,  while  others  who  have  made  a  careful  study 
of  this  method  claim  that  by  its  frequent  use  they  can  dispense  altogether 
with  the  internal  examination  in  a  large  proportion  of  cases.  In  the  first  stage 
of  labor  this  examination  will  not  differ  greatly  from  the  external  examination 
already  described  under  the  "  Examination  of  Pregnancy,"  page  150.  Exami- 
nations should  be  made  between  the  pains,  since  the  action  of  the  fetal  heart 
is  more  rapid  during  a  pain,  and  the  uterine  contractions  render  satisfactory 
palpation  difficult.  Although  the  diagnosis  by  external  manipulation  is  some- 
what more  difficult  at  this  time  than  before  labor,  it  is  usually  possible  to  obtain 
a  satisfactory  idea  of  the  position  and  presentation.  Important  facts  to  be 
noted  are:  (i)  The  position  and  presentation  (see  page  154);  (2)  the  rate 
and  character  of  the  fetal  heart-sounds  (see  page  129);  (3)  the  condition  of 
the  bladder  as  to  distention;  (4)  the  size-of  the  fetal  head  and  whether  or  not 
it  has  entered  or  can  be  made  to  enter  the  pelvic  cavity;  (5)  and  the  strength, 
duration,  and  frequency  of  the  uterine  contractions.  The  occurrence  of  the 
pains  at  regular  intervals  and  the  contraction  of  the  uterus  during  a  pain, 
which  may  be  appreciated  by  a  hand  placed  on  the  abdomen,  are  of  importance 
in  distinguishing  the  onset  of  true  labor.  The  sinking  of  the  uterus,  referred 
to  in  the  section  on  the  symptoms  and  signs  of  pregnancy,  which  occurs  during 
the  last  two  weeks  of  pregnancy,  is  also  of  some  significance.  The  characteristic 
shape  of  the  abdomen  when  the  membranes  have  ruptured  and  the  head  is 
low  in  the  vagina  soon  becomes  familiar  to  the  observer  and  denotes  that  the 
patient  is  far  advanced  in  labor. 

Pelvimetry. — Should  the  patient  be  a  primipara  who  has  not  been  sub- 
jected to  the  exaniination  of  pregnancy  (see  page  150),  the  routine  external 
pelvic  measurements — namely,  the  crests,  spines,  trochanters,  obliques,  and 
external  conjugate — should  be  taken,  and  if  pelvic  deformity  exist,  as  further 
indicated  by  the  internal  examination,  we  should  not  hesitate  to  make  a  thor- 
ough internal  examination  under  nitrous  oxid  or  ether,  passing  the  whole  hand, 
if  necessary,  into  the  pelvis  to  secure  accurate  data  of  the  available  space  at 
the  pelvic  inlet  (see  page  174).  If  the  patient  be  a  multipara,  all  these  careful 
measurements  in  private  practice  are  not  necessary  if  the  previous  children 
have  been  of  usual  size  and  the  labors  uneventful. 


THE   MANAGEMENT   OF   LABOR. 


475 


Internal    Examination. — After   the    external    examination,    the    patient 
having  already  been  prepared  as  described  on  page  472,  the  nurse  should  place 


-..'-"V„ 


SHEET 


! 


Fig.  614. — Vaginal  Examinations  during  Labor.  Position  of  the  Patient  and 
Separation  of  the  Vulva;  Introduction  of  the  Fingers  with  the  External 
Genitals  Exposed  to  View.      (Method  recommended.) 

her  in  the  dorsal  posture,  with  thighs  flexed,  parallel  with  the  edge  of  the  bed 
(Fig.  914).  The  external  genitals  and  vulval  canal  are  again  cleansed  from 
before  backward  by  the  nurse  with  i  :  2000   sublimate  solution  by  means  of 


476 


PHYSIOLOGICAL  LABOR. 


absorbent  cotton.  No  unsterilized  object,  hand,  instrument,  dressing,  or  cloth- 
ing, should  touch  the  genitals,  which  during  the  course  of  labor  are  covered 
with  a  sterile  vulval  pad.  The  physicians 's  hands  and  forearms  are  re-sterilized 
(see  page  150)  and  the  ostium  vaginae  is  exposed  by  separating  the  labia  with 
the  sterile  thumb  and  finger  of  the  left  hand  (Fig.  614).  The  sterile  first  and 
second  fingers  of  the  right  hand  are  now  passed  directly  into  the  vagina,  having 

come  in  contact  with  nothing  from 
^„  .  the  sublimate  solution  to  the  va- 

ginal entrance  (Fig.  614).  No  towel 
or  vaseline  should  be  used,  the  ex- 
amination being  made  while  the 
hand  is  still  moist  with  the  bichlo- 
ride solution. 

The  First  Vaginal  Examina- 
tion.— It  is  desirable  to  make  a 
careful  vaginal  examintion  as  early 
as  possible  in  the  first  stage  in  order 
to  verify  the  information,  as  to  the 
fetal  position  and  presentation, 
which  may  have  been  obtained  by 
external  palpation,  and  to  deter- 
mine the  existence  or  nonexistence 
of  conditions  in  the  pelvis  or  soft 
parts  which  would  prove  obstacles 
to  delivery,  unless  the  information 
has  already  been  obtained  at  the 
examination  during  pregnancy 
(page  150).  In  the  first  vaginal 
examination  during  labor  we 
should  strive  to  determine:  (i)  The 
condition  of  the  vulva  and  vagina 
as  to  dilatability  and  the  presence 
of  lubricating  mucus ;  (2)  the  con- 
dition of  the  bladder  and  rectum ; 
(3)  the  condition  of  the  cervix  as 
to  dilatability  and  degree  of  dilata- 
tion; (4)  is  pregnancy  present  ?  (5) 
is  the  woman  in  labor?  (6)  what  is 
the  stage  of  labor?  (7)  the  presence 
of  the  "bag  of  waters"  and  whether 
it  becomes  tense  during  a  pain,  an 
important  point  in  distinguishing 
true  from  false  labor  pains ;  (8)  the 
presentation  and  position;  (9)  the 
internal  conjugate  diameter;  (10) 
any  apparent  disproportion  be- 
tween the  presenting  part  and  the  capacity  of  the  pelvis;  (11)  the  effectiveness 
of  the  pains  on  the  os,  membranes,  and  presenting  part.  (12)  This  examination 
should  also  carefully  confirm  the  results  of  the  examination  during  pregnancy  as 
to  the  presence  of  pelvic  deformity  or  obstruction  in  the  soft  parts  and  as  to  the 
fetal  position  and  presentation.  If  any  suspicion  of  pelvic  deformity  exist,  the 
true  conjugate  should  be  estimated,  the  height  of  the  symphysis  noted,  the  lateral 


Fig.  615. —  Vaginal  Examinations  during 
Labor.  The  External  Genitals  are  not 
Exposed  to  View.  (This  method  is  not  re- 
ccmmended.) 


THE  MANAGEMENT   OF   LABOR.  A:TJ 

surfaces  of  the  pelvis  palpated,  and  the  methods  of  determining  the  actual  degree 
of  pelvic  deformity  applied ;  t)iese  have  already  been  described  under  the  "  Exam- 
ination of  Pregnancy,"  page  1 50.  If  the  vertex  presents  and  descends  regularly 
with  the  pains,  and  if  the  patient's  general  and  local  condition  is  satisfactory,  in- 
terference, and  especially  the  passing  of  the  finger  through  the  os  uteri,  owing 
to  increased  danger  of  sepsis,  is  to  be  scrupulously  avoided.  Noticeable  delay, 
however,  in  the  progress  of  labor  should  be  carefully  investigated,  and,  if 
necessary,  under  anesthesia,  as  will  be  described  in  the  section  on  delayed 
labor. 

Repetition  of  Vaginal  Examinations. — It  was  formerly  the  custom  to 
make  frequent  examinations  during  the  whole  course  of  normal  labor,  and  this 
is  still  taught  in  some  text-books,  but  the  consensus  of  modern  teaching  is  to  the 
effect  that  such  a  course  is  unnecessary  and  dangerous  (see  page  149)-  It  is  true 
that,  with  proper  care  as  to  asepsis,  the  danger  of  infection  is  limited,  but  it  never- 
theless exists,  since  even  with  the  greatest  care  it  is  impossible  to  exclude  all 
sources  of  contamination.  Examinations  are  also  annoying  to  the  sensibilities  of 
the  patient,  and  when  frequently  repeated  they  sometimes  become  extremely  pain- 
ful. They  tend  to  remove  the  vaginal  mucus  which  nature  has  provided  for  lubri- 
cating the  parts  and  to  cause  erosions  of  the  mucous  membranes  which  may  serve 
as  starting-points  for  septic  infection.  Their  frequent  repetition  has  in  many 
cases  a  bad  effect  on  the  nervous  system,  and  undoubtedly  contributes  at  times 
reflexly  to  delay  the  progress  of  labor.  It  is  nevertheless  true  that  it  is  the 
duty  of  the  attendant  to  keep  himself  informed  of  the  progress  of  his  patient, 
and  that  this  may,  at  least  in  the  case  of  beginners,  require  two  or  three 
vaginal  examinations.  Increasing  experience  diminishes  the  necessity  for 
vaginal  examinations,  and  it  should  be  the  effort  of  the  physician  to  acquire 
such  familiarity  with  abdominal  palpation  and  the  clinical  history  of  labor  that 
the  necessity  for  frequent  examinations  may  not  exist. 

Having  made  the  first  examination,  the  attendant  should  endeavor  as  far  as 
possible  to  determine  the  further  progress  of  labor  by  external  palpation  and  by 
observation  of  the  patient,  but  if  in  doubt,  he  should  repeat  the  examination  often 
enough  to  satisfy  himself  as  to  the  non-existence  of  a  delayed  first  stage.  Exact 
rules  as  to  the  frequency  of  examination  cannot  be  given,  but  modem  investi- 
gation tends  to  the  conclusion  that  in  normal  cases  one  careful  examination  early 
in  the  first  stage  and  another  after  the  rupture  of  the  membranes  should  be 
sufficient  for  the  experienced  accoucheur.  Examination  after  rupture  of  the 
membranes  may  guard  one  against  the  neglect  of  face  presentation,  which  some- 
times occurs  at  this  time,  and  of  prolapse  of  small  parts  of  the  fetus  or  of  the 
cord;  it  determines  also  the  exact  position  of  the  head.  It  cannot  be  too  em- 
phatically stated  that  pregnant,  parturient,  and  puerperal  women  can  be  fatally 
infected  by  a  single  careless  internal  examination.  Some  danger  of  infection  is 
always  present,  therefore  internal  examinations  should  be  as  infrequent  as 
possible. 

In  many  instances  it  is  possible  to  conduct  a  labor  without  any  internal 
examination,  since  the  chief  information  gained  through  the  vagina  is  the  stage 
of  dilatation  of  the  cervix,  and  this  is  often  not  specially  important  to  know. 
Leopold  and  Sporling  *  and  Leopold  and  Orb  f  believe  that  it  is  possible  to 
conduct  safely  90  per  cent,  of  all  labors  without  any  other  than  external  methods 
of  examination.  Among  the  first  1000  cases  of  these  observers  there  were  only 
6.5  per  cent,  of  errors  of  diagnosis,  while  in  the  second  thousand  the  percentage 
was  only  1.77  per  cent, 

*  "  Arch,  fur  Gyn.,"  XLV,  339-371.  t  "  Arch,  fur  Gyn.,"  xlviii,  304-323. 


478  PHYSIOLOGICAL   LABOR. 


MANAGEMENT  OF  THE  FIRST  STAGE. 

This  stage  commences  with  the  onset  of  true  labor  pains  and  ends  with  the 
full  dilatation  or  dilatability  of  the  os  uteri.  The  conduct  of  the  obstetrician 
during  this  stage  is  usually  passive,  provided  no  evidences  of  maternal  or  fetal 
dystocia  have  been  discovered  at  the  examination  either  during  pregnancy  or 
during  labor. 

Posture  of  the  Patient. — In  the  absence  of  any  abnormal  conditions,  such  as 
hemorrhage,  placenta  praevia,  or  prolapse  of  the  funis,  the  patient  may  follow 
pretty  much  her  own  inclinations  as  regards  sitting  up,  walking  about,  or  lying 
down.  In  prolonged  labor,  especially  in  primiparse,  sitting  erect  or  walking 
about  the  room  is  of  advantage  in  assisting  dilatation  of  the  os  and  fixation  of 
the  head.  As  soon,  however,  as  the  os  is  nearly  dilated  or  dilatable,  and  the 
membranes  are  about  to  rupture,  the  patient  must  be  placed  in  the  dorsal  or 
lateral  recumbent  position,  until  the  membranes  rupture  or  are  ruptured  arti- 
ficially. Should  rupture  occur  when  the  patient  is  in  the  erect  posture,  there  is 
danger  of  prolapse  of  the  cord  or  of  one  of  the  fetal  extremities. 

Presence  of  the  Physician. — His  presence  in  the  lying-in  room  is  not  usually 
advisable  at  this  time,  but  in  multiparas  and  in  rapidly  progressing  labors  in 
primiparse  it  is  best  that  he  be  within  call. 

Vaginal  Examination. — Repetition  of  the  examination  during  labor  (page 
149)  is  usually  not  necessar}^  although  many  advise  an  immediate  examination 
when  the  membranes  rupture  so  as  to  exclude  prolapse  of  the  funis.  Frequent 
abdominal  palpation  will  generally  suffice  for  following  the  progress  of  labor  (see 
page  154). 

Food,  Drink,  Sleep,  Attention  to  Bladder  and  Rectum. — In  prolonged  labors 
the  patient  should  be  encouraged  to  take  at  intervals  during  the  first  stage  small 
quantities  of  liquid  nourishment,  such  as  plain  milk  or  milk  and  carbonic  water, 
or  simple  broths  or  soups,  such  as  chicken,  clam,  or  beef.  I  am  accus- 
tomed to  forbid  the  use  of  solid  food,  in  view  of  the  fact  that  ether  or 
chloroform  narcosis  may  subsequently  be  demanded.  No  restriction  should  be' 
placed  on  the  amount  of  water  desired  by  the  patient.  When  there  is  nausea 
or  vomiting,  very  hot  clear  tea  or  black" coffee  can  advantageously  replace  the 
water.  In  the  absence  of  a  positive  indication  alcohol  should  be  avoided.  The 
patient  should  be  induced  and  aided  to  sleep,  if  possible,  between  the  pains, 
especially  if  labor  commences  at  night,  since  a  sleepless  night  is  a  bad  prepara- 
tion for  labor.  The  patient  should  empty  the  bladder  at  frequent  intervals, 
since  its  distention  is  a  common  cause  of  delay  at  this  time.  The  catheter 
should  be  avoided.  If  the  rectum  has  not  already  been  emptied,  or  if  it  refills 
again,  a  copious  enema  should  be  given. 

Use  of  the  Voluntary  Forces. — In  any  but  exceptional  cases  voluntary 
bearing-down  efforts  on  the  part  of  the  patient,  either  with  or  without  the  aid  of 
bandages  of  bed-sheets  used  as  traction  straps  for  the  hands,  should  be  dis- 
couraged. Such  proceedings  only  fatigue  the  patient  and  usually  do  not  aid 
the  progress  of  labor. 

Care  of  Membranes. — Every  precaution  should  be  taken  against  the  acci- 
dental rupture  of  the  membranes,  either  by  vaginal  examination  or  by  sudden 
movements  of  the  patient,  in  order  to  avoid  a  dry  labor  and  its  consequences 
(see  Part  V). 

Anesthesia. — (See  Operations,  Part  X.) 


THE  MANAGEMENT   OF   LABOR.  479 


MANAGEMENT  OF  THE  SECOND  STAGE. 

This  stage  commences  with  full  dilatation  or  full  dilatability  of  the  os,  and 
ends  with  the  complete  expulsion  of  the  fetus  or  fetuses. 

Posture  of  the  Patient. — At  or  near  the  end  of  the  first  stage  the  patient 
should  be  placed  in  bed,  and,  as  a  rule,  must  remain  there  until  the  completion 
of  the  second  stage,  the  bed-pan  being  used  for  evacuations  of  the  bladder  and 
bowels.  As  the  period  of  fetal  expulsion  approaches,  the  patient  is  placed  in 
the  position,  dorsal  or  lateral,  preferred  by  the  physician,  and  the  nurse  is 
instructed  to  draw  up  and  pin  at  the  shoulders  the  night-clothing  to  pro- 
tect it  from  soiling.  An  ordinary  bed-sheet  may  be  pinned  about  the  waist 
like  a  skirt  to  cover  the  lower  part  of  the  body  and  as  a  further  protection 
against  soiling. 

Presence  of  the  Physician. — Usually  he  should  not  absent  himself  during 
this  time. 

Vaginal  Examination. — In  the  absence  of  dystocia,  abdominal  palpation 
may  be  relied  upon  for  determining  the  course  of  labor  (page  154). 

Food,  Drink,  Sleep,  Attention  to  Bladder  and  Rectum. — The  same  principles 
apply  here  as  in  the  first  stage,  with  the  exception  of  sleep  (page  478).  The 
second  stage  is  usually  so  short  that  it  is  rarely  necessary  to  feed  the  patient. 
Care  should  be  taken,  however,  that  both  bladder  and  rectum  are  empty  at  this 
time.  The  presence  of  a  distended  bladder  can  be  determined  by  external 
examination. 

Use  of  Voluntary  Forces. — In  the  second  stage,  and  especially  when  it  is 
protracted,  the  patient  should  be  encouraged  to  bear  down  during  the  pains. 
Much  can  be  accomplished  by  instructing  the  woman  to  hold  her  breath  and  bear 
down  as  a  contraction  reaches  its  height.  If  the  contractions  are  severe  and 
painful  and  the  patient  does  not  bear  them  well,  she  may  be  induced  to  bear 
down  by  being  allowed  to  inhale  a  few  drops  of  ether  or  chloroform  at  the  begin- 
ning of  each  pain.  Other  legitimate  and  simple  measures  to  overcome  inefficient 
contractions  at  this  time  are  having  the  patient  repeatedly  assume  a  sitting 
posture  on  the  edge  of  the  bed,  or  even  on  a  chair;  pulling  upon  the  hands  of  the 
nurse ;  bracing  the  feet  against  the  foot  of  the  bed ;  pulling  with  both  hands  upon 
slings  made  of  stout  roller  "bandages  fastened  to  the  bed  below  the  feet.  (See 
Prolonged  Labor.)  For  a  too  rapid  expulsion  anesthesia  is  our  sheet-anchor; 
instructing  the  patient  not  to  bear  down  is  also  useful. 

Artificial  Rupture  of  the  Membranes. — The  membranes  usually  rupture 
spontaneously  at  or  near  the  completion  of  the  first  stage  after  their  purpose 
has  been  accomplished.  Earlier  rupture  is  not  uncommon.  A  common  and 
pernicious  practice  is  the  early  artificial  rupture  of  the  membranes  to  accelerate 
labor.  As  a  rule,  they  should  not  be  interfered  with,  even  though  they  distend 
the  vulva.  Indications  may  arise  which  demand  their  artificial  rupture.  (See 
Operations,  Part  X.) 

Anesthesia. — (See  Operations,  Part  X.) 

Perineal  Protection.* — When  the  presenting  part  approaches  the  pelvic 
floor  and  vulva,  preparations  are  to  be  raade  to  protect  the  perineum  from 
rupture.  The  most  important  part  of  the  management  of  the  second  stage  is 
the  prevention  of  perineal  tears.  Lacerations  of  the  fourchette  in  primiparae 
and  superficial  tears  about  the  vulval  orifice  often  occur,  but  these  readily  heal 

*  For  the  varieties,  frequency,  etiology,  mechanism,  symptoms,  diagnosis,  prognosis, 
and  prophylaxis  of  perineal  injuries,  see  Pathological  Labor,  Part  V.  For  the  treatment  of 
the  same,  consult  the  section  on  Obstetric  Surgery,  Part  X. 


480  PHYSIOLOGICAL   LABOR. 

with  simple  asepsis.  Deep  tears,  however,  are  avoidable  in  normal  cases.  The 
great  importance  of  avoiding  rupture  of  the  perineum  cannot  be  overestimated. 
It  is  scarcely  an  exaggeration  to  state  that  one-half  of  the  gynecological  cases 
owe  their  condition  directly  or  indirectly  to  rupture  of  the  muscles  of  the  pelvic 
floor  during  labor.  The  causes  of  perineal  laceration  are  three  in  number, 
namely:  (i)  Relative  disproportion  in  size  between  the  presenting  part  and  the 
pelvic  outlet;  (2)  too  rapid  expulsion,  so  that  tearing  instead  of  stretching  re- 
sults; (3)  and  faulty  mechanism  of  labor  whereby  a  larger  circumference  of  the 
presenting  part  than  necessary  passes  through  the  outlet. 

Prophylaxis  depends  upon  the  cause.*  If  there  is  great  disproportion  in 
size  or  abnormal  rigidity  of  the  outlet,  abundance  of  time  must  be  given  to  the 
muscles  of  the  pelvic  floor  to  stretch  sufficiently  without  tearing  to  permit  of 
the  passage  of  the  fetus.  Preliminary  digital  stretching  as  well  as  the  use  of 
chloroform  will  assist  in  the  relaxation  of  these  muscles,  and  if  all  attempts  fail 
and  conditions  do  not  permit  of  further  delay,  episiotomy,  properly  performed 
and  repaired,  is  preferable  to  deep  perineal  rupture  (see  Obstetric  Operations, 
Part  X).  The  chief  ends  in  view  are  (i)  to  prevent  too  rapid  expulsion;  (2)  to 
preserve  the  normal  mechanism  of  delivery,  and,  if  possible,  (3)  to  effect  delivery 
of  the  head  between  the  pains. 

1.  The  too  rapid  advance  of  the  head  can  be  prevented  by  inducing  the  patient 
to  refrain  from  bearing-down  efforts,  to  breathe  rapidly  during  the  pains,  and  to 
cry  out  during  the  emergence  of  the  head ;  by  the  manual  retardation  of  the  pre- 
senting part  and  by  the  administration  of  chloroform  or  ether.  Partial  anesthesia 
is  an  invaluable  resource,  aiding  relaxation  of  the  tissues,  preventing  too  rapid 
expulsion,  and  allowing  of  complete  control  of  the  case.  The  advance  of  the 
head  should  be  retarded  by  pressure  applied  not  to  the  perineum  but  to  the 
presenting  part.  No  attempt  should  ever  be  made  to  support  the  perineum 
directly,  and  all  methods  of  perineal  protection  which  depend  upon  intrarectal 
manipulations  of  any  character  should  be  carefully  avoided,  as  liable  to  injure 
the  rectum,  produce  spasm  of  the  pelvic  floor  muscles,  and  favor  subsequent 
infection  of  the  genital  tract  or  the  eyes  or  umbilicus  of  the  child. 

2.  The  normal  mechanism  of  delivery  should  be  aimed  at  so  as  to  secure  the 
smallest  possible  diameters  of  the  presenting  part  to  pass  through  the  parturient 
outlet.  A  valuable  point  in  vertex  anterior  positions  is  so  to  retard  extension 
of  the  head,  until  the  external  occipital  protuberance  has  passed  the  subpubic 
ligament,  that  the  smallest  or  suboccipito-bregmatic  circumference  (Fig.  574) 
may  be  the  one  to  engage  and  pass  through  the  outlet. 

3.  Delivery  of  the  head  between  the  uterine  contractions  has  a  distinct  advantage 
in  that  we  have  a  relaxed  instead  of  a  rigidly  contracted  pelvic  floor  to  deal  with. 
Method  second  or  third  will  accomplish  this  end. 

Methods  of  Perineal  Protection. — Any  of  the  various  postures  of  the  patient 
may  be  selected,  but  I  advise  the  left  lateral  prone  posture  for  left  positions  of 
the  presenting  part,  and  the  right  lateral  prone  posture  for  right  positions.  It 
is  generally  admitted  that  the  lateral  position  is  most  favorable  to  perineal 
preservation.  In  this  position  the  force  of  violent  pains  is  diminished,  since 
the  expulsive  power  here  is  actually  a  resultant  of  two  divergent  forces.  In  the 
lateral  and  latero-prone  positions  the  intra-abdominal  pressure  is  also  weakened, 
and  the  perineum  is  always  under  ocular  control.  Further,  disinfection  may  be 
carried  out  more  completely  in  the  lateral  decubitus.  In  the  dorsal  posture  the 
weight  of  the  head  carries  the  latter  away  from  the  pubic  arch  and  against  the 
perineum;  this  condition  is  not  favorable  to  the  latter.     While  this  disadvantage 

*  Compare  Pathological  Labor,  Part  V. 


THE  MANAGEMENT   OF   LABOR. 


481 


may  be  oflfset  by  the  upward  pressure  of  the  posterior  segment  of  the  perineum 
toward  the  symphysis,  the  former  thereby  becomes  ischemic,  thin,  and  more  prone 


second.  third. 

Fig.   6i6. — Perineal  Protectio:^,   showing  Three   Methods. 


to  rupture.     The  thighs,  however,  should  not  be  too  energetically  flexed,  other- 
wise the  perineum  will  be  put  upon  a  dangerous  stretch.    After  delivery  the  lateral 
posture  must  be  quickly  changed  to  the  dorsal,  lest  air  embolus  result.     Among 
31 


482 


PHYSIOLOGICAL   LABOR 


Fig.  617. — Cleansing  the  Eyelids   Immediately 

AFTER    THE    BiRTH    OF    THE    HeAD. 


primitive  people  a  squatting  or  kneeling  position  is  often  instinctively  adopted 
during  delivery,  but  it  cannot  be  claimed  that  such  postures  favor  the  perineum, 
as  labor  under  these  circumstances  has  a  precipitate  character.  While  labor  may 
be  shortened  and  facilitated  by  these  attitudes,  the  safety  of  the  perineum  would 
seem  to  demand  that  the  lateral  position  should  be  assumed  during  the  moment 
of  expulsion.  Any  of  the  following  methods  may  be  utilized,  as  all  are  subservient 
to  the  principles  already  laid  down.    The  principle  in  all  methods  of  direct  manual 

protection  of  the  perineum  is  to 
delay  expulsion  of  the  presenting 
part  in  such  manner  as  to  realize 
all  the  advantages  of  the  elas- 
ticity of  the  perineum.  The  de- 
gree of  latent  elasticity  of  this 
structure  may  be  determined  by 
inspection.  The  fetal  head,  or 
other  presenting  part,  should  be 
supported  rather  than  the  peri- 
neum. In  fact,  the  attempt  to 
support  the  latter  is  attended  by 
danger. 

Method  one:  The  patient  is 
placed  in  the  lateral  prone  pos- 
ture. In  the  left  lateral  prone 
posture  the  physician,  seated  at 
the  bedside  behind  the  patient, 
passes  the  left  hand  and  forearm  over  the  right  thigh  of  the  patient  and  uses  the 
fingers  of  this  hand  to  retard  the  exit  of  the  presenting  part,  and  also  to  assist, 
to  a  small  extent,  the  normal  mechanism  of  labor  until  the  pelvic  floor  is  suffi- 
ciently stretched  to  allow  the  passage  of  the  fetus  without  laceration  (Fig.  616).  At 
the  same  time,  with  two  or  three  fingers  of  the  right  hand  placed  upon  the  protrud- 
ing head,  and  without  touching  any  part  of  the  maternal  tissues,  control  of  the 
expulsion  and  regulation  of  the  head  movements  can  readily  be  carried  out  (Fig. 
616).  In  this  method  both  hands  are 
used  to  control  a  too  rapid  advance  and  '-—--._ 
conjointly  to  regulate  the  head  move- 
ments, so  as  to  secure  the  most  favorable 
mechanism  of  head  delivery.  Chloro- 
form or  ether  will  greatly  assist  our  en- 
deavors . 

Method  two:  The  posture  of  the  pa- 
tient and  the  position  of  the  physician 
are  the  same  as  in  Method  One.  Chloro- 
form or  ether  is  invaluable.  The  position 
and  functions  of  the  left  hand  are  the 
same  as  above.     At  the  same  time,  with 

the  fingers  of  the  right  hand  (Fig.  616)  placed  on  each  side  of  the  coccyx,  over  the 
extremities  of  the  bitemporal  diameter  of  the  fetal  head,  the  presenting  part  is 
pushed  up  as  close  to  the  subpubic  ligament  as  possible,  thus  making  use  of  all 
the  available  space  of  the  pubic  arch.  The  use  of  chloroform  or  ether  to  the 
obstetric  degree,  and  the  delivery  of  the  presenting  part  during  perineal  relaxa- 
tion between  the  pains,  by  pressure  with  the  fingers  on  either  side  of  the  coccyx, 
or  by  expressio  jcrtus  (Part  X) ,  will  greatly  lessen  the  chances  of  rupture.     Exten- 


FiG.  618. — Little  Finger  Wrapped  with 
Gauze  for  Removing  Mucus  from  the 
Child's  Mouth. 


THE  MANAGEMENT   OF   LABOR. 


483 


sion  and  delivery  of  the  head  should  never  be  permitted  until  the  external  occi- 
pital protuberance  has  beefi  bom  be- 
yond the  arch  of  the  pubes. 

Method  three:  Lateral  posture  and 
chloroform  or  ether,  as  above.  In  the 
left  lateral  posture  the  right,  and  in 
the  right  posture  the  left,  hand  is  used 
for  perineal  protection.  In  the  dorsal 
posture  of  the  patient  either  hand  is 
available.  By  the  natural  forces  or 
by  pressure  upon  the  fundus  the  head 
is  made  to  distend  the  vulva  suffi- 
ciently to  enable  the  middle  finger  of 
the  perineal  hand  to  obtain  a  point 
of  pressure  upon  the  forehead  of  the 
fetus  by  reaching  behind  the  anus  but 
without  entering  the  rectum  (Fig. 
6i6).  The  thumb  of  the  hand  is  then 
placed  upon  one  labium  majus  and  the 
index-finger  upon  the  other  over  the  parietal  protuberances  of  the  advancing 


Fig.  619. — Method  of  Loosening  and  Car- 
rying THE  Cord  over  the  Head  when 
THE  Former  is  Tightly  Coiled  about  thb 
Child's  Neck. 


\N 


\:o     >CERV!Qb5\CR^IALD, 

\>.  I 
\^  I 


Fig  620. — Method  of  Shoulder  Delivery.  The  Head  is  Raised  to  Bring  thb 
Neck  Close  to  the  Pubes,  and  the  Anterior  Shoulder  well  behind  the 
Symphysis,  thus    Encouraging    Delivery    of    the    Posterior    Shoulder    First, 

WITH    THE    CeRVICO-ACROMIAL    DiAMETER    ENGAGING. 


484 


PHY  BIOLOGICAL   LABOR. 


head  (Fig.  6i6),  and  serve  to  draw  the  labia  inward  and  backward  and  prevent 
undue  strain  upon  the  posterior  commissure,  which  Hes  in  plain  sight  above  the 


Fig.  621. — Method  of  Shoulder  Delivery.  The  Anterior  Shoulder  is  here  Born 
First,  and  the  Head  is  Raised  to  Encourage  Expulsion  of  the  Posterior 
Shoulder. 


S«U«*'ifJ«-'-""'<»i"1«>— • 


Fig.  622. — Supporting  the  Child  during  the  Expulsion  of  the  Trunk  and  Legs. 
Note  that  the  trunk  is  grasped  at  the  pelvis,  leaving  the  chest  and  abdomen  free  from 
pressure. 


THE  MANAGEMENT   OF   LABOR. 


485 


web  between  the  thumb  and  forefinger.     Pressure  of  the  fingers  upon  the  parietal 
eminences  prevents  the  too  sudden  advance  of  the  head,  while  the  middle  finger 


Fig.  623. — Proper  Position  of  the  Child  Immediately  after  Delivery.  It  lies  on 
its  right  side  and  the  buttocks  are  raised  to  favor  the  flow  of  mucus  and  foreign  sub- 
stances from  the  mouth. — (From  a  photograph  taken  at  the  Emergency  Hospital.) 


reaching  behind  the  anus  and  protected  by  a  sterile  towel  exerts  pressure  upon 
the    forehead,  and .  at   the  proper 
moment  during  the  relaxation  be  / 

tween  the  pains  increases  head  ex- 
tension   and    slowly   shells    it    out 
through  the  vulval  opening.     Mod- 
erate fundal  pressure  with  the  free  /  / 
hand  may  assist  in  the  manoeuver.         ; 

Cleansing  of  Eyes  and  Mouth. — 
After  the  delivery  of  the  head,  the 
eyelids  should  be  carefully  cleaned 
by  means  of  a  soft  linen  cloth  and 

sterile  water,  or  boric  acid  solution ;  '     ■^- 

a  separate  wipe  being  used  for  each 
eye  and  the  lids  washed,  from  the 

nose  outward,  free  from  all  mucus, 

ii^^j    ^^  .^ ^    :..^„        A+  +-u;^ +'-„^      Fig.  624.— Method  of    "Stripping"   the  Um- 

blood,  or  mecomum.      At  this  time  ^^^^^^^   ^^^^   ^^    Remove    the    Excess    of 

also  the  lips  and  nose  are  in  like         Wharton's  Jelly. 


486 


PHYSIOLOGICAL   LABOR. 


Fig.  625. — Method  of  Tightening  the  Liga- 
ture ABOUT  THE  Umbilical  Cord.  Note  the 
position  of  the  thumbs  to  prevent  injury  to 
the  ring  from  cutting  or  breaking  of  the  liga- 
ture. 


manner  wiped  free  of  mucus,  and  the  little  finger,  wrapped  with  a  piece  of  moist 
linen,  is  passed  into  the  child's  mouth  and  any  accumulated  mucus  removed  by 
an  outward  sweep  of  the  finger  (Fig.  618). 

Care  of  the  Cord  about  Neck. — Search  should  be  made  to  discover  whether  the 
cord  encircles  the  neck,  and  if  it  does  a  loop  should  be  enlarged  and  drawn  over 

the  head;  but  if  this  cannot  be 
done,  the  funis  should  be  cut  be- 
tween a  double  ligature,  or,  if  time 
is  lacking,  without  the  application 
of  ligatures  (Fig.  619). 

Delivery  of  the  Shoulders. — 
After  the  head  is  bom,  in  the  ab- 
sence of  any  indication  for  immedi- 
ate delivery,  it  is  better  to  wait  for 
natural  expulsion  of  the  shoulders 
and  body,  the  head  in  the  mean 
time  being  supported  in  the  flat  of 
the  hand  (Fig.  620). 

Preservation  of  Perineum  dur- 
ing Delivery  of  Shoulders. — This  is 
best  attained  by  preserving  the 
normal  mechanism  of  shoulder  de- 
livery (see  page  447).  Delivery  of 
the  shoulders  should  be  delayed  if 
possible  until  nearly  complete  rotation  of  the  bisacromial  diameter  has  taken 
place.  The  head  should  be  held  in  the  hand  and  gently  raised  so  as  to  bring  the 
anterior  shoulder  well  up  behind  the  symphysis,  thus  securing  the  cervico-acromial 
diameter  of  the  fetus  at  the  outlet  instead  of  the  bisacromial  (Fig.  620).  The 
posterior  shoulder  is  thus  permitted  to  be  delivered  first,  contrary  to  the  common 
custom,  and  should  be 

carefully   guided   in   its  /' 

passage  over  the  peri- 
neum. Shoulder  delivery 
should  be  accomplished 
whenever  possible  by 
the  natural  forces,  since 
I  have  found  that  man- 
ual extraction  increases 
the  number  of  perineal 
lacerations.  Care  should 
be  taken  lest  during  the 
delivery  of  the  shoul- 
ders an  existing  lacer- 
ation caused  by  the  head 
be  increased  in  size. 
During  the  detentionof 

the  anterior  shoulder  behind  the  pubis  the  fetal  hand  of  the  opposite  arm  lying 
across  the  child's  chest  will  usually  soon  appear  in  the  vulva.  Delivery,  we  have 
found,  is  assisted  by  slowly  flexing  this  forearm  and  arm  out  through  the  vulva  and 
thus  delivering  the  posterior  shoulder  by  slight  traction  on  the  posterior  arm. 
Should  there  be  delay  in  the  expulsion  of  the  posterior  shoulder,  traction  upward 
upon  the  head,  the  fingers  encircling  the  neck,  is  to  be  preferred  to  traction  with  a 


\ 


\ 


Fig.  626. — Method  of  Cutting  the  Umbilical  Cord  after 
THE  Application  of  the  Two  Ligatures. 


THE  MANAGEMENT   OF   LABOR. 


487 


finger  in  the  axilla.    (See  Part  X.)     Should  there  be  delay  in  the  delivery  of  the 
anterior  shoulder,  it  is  best  remedied  by  making  traction  directly  downward 


Fig.  627. — Method  of  Inspecting  the 
Stump  of  the  Umbilical  Cord  for 
Hemorrhage. 


Fig.  628. — Method  of  Instilling  Drops 
OF  Nitrate  of  Silver  Solution  into 
THE   Eye  of  the  Newly  Born  Child. 


£^': 


Fig.   629. — Method  of  Lifting  the  Newly   Born  Child  with  One    Hand. —  {From   a 
photograph  taken  at  the  Emergency  Hospital.) 


488  PHYSIOLOGICAL   LABOR. 

with  the  hands  placed  on  the  sides  of  the  head,  taking  care  not  to  injure  the  peri- 
neum. If  this  does  not  succeed,  traction  may  be  made  by  a  finger  in  the  axilla. 
(See  Part  X.) 

Delivery  of  Body,  Pressure  on  Fundus. — After  delivery  of  the  shoulders  the 
body  is,  as  a  rule,  rapidly  expelled.  Should  there  be  delay,  however,  the  thorax 
may  be  grasped  with  the  hands  and  gentle  traction  made,  or,  better,  the  fetus 
expelled  by  pressure  upon  the  fundus.  In  the  delivery  of  the  shoulders  and 
body  of  the  fetus  the  general  principle — namely,  to  make  use  of  all  the  available 
space  of  the  pubic  arch — is  followed.  To  accomplish  this,  the  shoulders  and  body 
are  not  permitted  to  press  too  closely  against  the  perineum,  but  are  rather  pushed 
carefully  into  the  pubic  arch.  During  the  expulsion  of  the  fetus  the  fundus  is 
followed  down  by  the  hand  of  the  physician  or  assistant,  and  must  be  watched 
for  at  least  an  hour.     This  dutv  mav  be  releg^ated  to  an  assistant  or  a  nurse. 


\ 


Fig.  630. — Method  of  Lifting  the  Newly  Born  Child  with  Two  Hands. — {From  a 
photograph  taken  at  the  Emergency  Hospital.) 

Care  and  Posture  of  the  Child  in  Bed. — If  the  child  cries  vigorously,  measures 
for  establishing  respiration  are  unnecessary,  and  all  rough  handling  should  be 
avoided.  It  should  be  wrapped  in  a  warm  blanket  previously  prepared  and 
allowed  to  rest  between  the  mother's  thighs  until  after  ligation  of  the  cord  (Fig. 
623).  It  should  be  placed  upon  the  right  side,  since  this  posture  tends  to  aid  the 
physiological  changes  in  the  fetal  circulation,  and  with  head  low  to  prevent  cere- 
bral anemia. 

Establishment  of  Respiration. — Should  the  child  cry  out  feebly,  or  should  there 
be  any  delay  in  the  establishment  of  respiration,  it  should  be  smartly  slapped  upon 
the  buttocks  or  a  few  drops  of  cold  water  should  be  dashed  upon  the  face  and 
chest.  In  feeble  or  premature  children,  however,  all  rough  handling  should  be 
avoided.     (See  Asphyxia  Neonatorum,  Part  IX.) 

Ligation  of  the  Cord. — Respiration  being  fully  established,  the  ligation  of 


THE  MANAGEMENT  OF   LABOR. 


489 


the  cord  should  be  delayed  until  pulsations  cease,  unless  there  is  some  positive 
indication  to  the  contrary.  Immediate  ligation  deprives  the  fetus  of  about 
three  ounces  of  blood. 
Before  ligation  it  is  a 
good  plan  to  grasp  the 
cord  with  the  thumb  and 
first  finger  of  one  hand 
close  to  the  navel,  care 
being  taken  not  to  make 
traction,  and  with  the 
fingers  of  the  free  hand 
to  strip  away  the  gelatin 
of  Wharton  from  the 
fetus  for  a  distance  of 
two  or  three  inches  (Fig. 
624).  This  gives  a  thin 
stump  for  subsequent 
separation.  The  cord  is 
now  ligated  with  sterile 
bobbin  or  floss  silk, 
about  li  inches  from  the 
umbilicus,  it  being  first 
determined  that  no  les- 
ion of  the  cord  exists.  A 
second  ligature  is  then 
placed  about  two  inches 
from  the  first  in  order  to 
prevent  hemorrhage  in 
case  of  twins,  but  chiefly 

to  retain  blood  in  the  placenta  that  the  uterus  may  more   readily  expel  it 
Division  of  the  cord  with  scissors  is  now  performed  close  to  the  first  ligature, 


^ 


W 


Fig.  631. — Method  of  Inspecting  the  Lower  Vagina  and 
Perineum  for  Lacerations  at  the  Completion  of  Labor. 


Fig.  632. — Testing  the  Amount  of  Injury  to  the  Perineum. 


This  is  best  done  in  the  hollow  of  the  hand,  the  scissors  being  passed  between 
the  second  and  third  fingers  to  avoid  injury  to  the  actively  moving  extremities  and 
unnecessary  spurting  of  blood  (Fig.  626).     Some  amputate  the  cord  close  to  the 


490 


PHYSIOLOGICAL   LABOR. 


umbilicus  and  bring  the  edges  together  with  fine  sutures  (Dickinson).  I  have 
been  unable  to  determine  that  this  procedure  possesses  any  advantages  over  the 
ordinary  method.  The  stump  of  the  cord  is  now  touched  with  sublimate  solu- 
tion ( I  :  2000)  and  a  dry  occlusion  dressing  of  absorbent  cotton  or  gauze  is  ap- 
plied (Fig.  627). 

Care  of  Child. — The  child,  wrapped  in  some  warm  material,  is  placed  upon  its 
right  side  with  its  head  lower  than  its  body  in  some  safe  spot  where  it  will  not  be 
liable  to  fall  to  the  floor  or  be  sat  upon.  In  lifting  a  naked,  slippery  child  from 
the  bed  to  wrap  it  in  a  blanket  one  may  grasp  it  as  in  Fig.  629  by  one  hand,  or 
with  two  hands,  as  in  Fig.  630.  In  both  instances  the  head  in  a  state  of  flexion 
should  be  allowed  to  hang  lower  than  the  body.  Either  of  these  methods  is  recom- 
mended for  physiological  reasons. 

Prevention  of  Ophthalmia. — As  soon  after  birth  as  convenient  the  eyes  and 
lids  are  again  wiped  clear  of  mucus  and  2  drops  of  a  i  per  cent,  solution  of  nitrate 

of  silver  are  dropped  into  each  eye  (Fig.  628). 
This  is  strongly  advised  both  in  private  and  hos- 
pital practice. 

Inspection  of  Perineum  (Fig.  631). — Immedi- 
ately after  the  completion  of  the  second  stage  the 
patient  should  be  carefully  turned  over  from  the 
lateral  to  the  dorsal  posture  to  avoid  air  embolus. 
I  am  accustomed  to  inspect  the  perineum  at  this 
time  instead  of  waiting  for  the  completion  of  the 
third  stage.  My  reason  for  this  is  that  it  can  be 
more  readily  done  now  on  accotmt  of  the  partial 
anesthesia  of  the  second  stage.  The  perineum 
and  vagina  should  be  carefully  examined,  as  many 
severe  lacerations  are  not  visible  externally.  The 
labia  are  separated  by  the  fingers  wrapped  in  ster- 
ile gauze  or  cotton,  both  hands  being  used,  and 
the  parts  thoroughly  inspected.  Here  as  else- 
where, however,  intra-rectal  manipulations  are  to 
be  avoided  if  possible.  The  occurrence  of  rather 
free  hemorrhage  during  the  latter  part  of  the 
second  stage  may  indicate  a  vaginal  laceration. 
Preliminary  Vulval  Dressing  (Fig.  633). — Immediately  after  the  expulsion 
of  the  child,  I  am  accustomed  to  place  over  the  gaping  vulva  an  antiseptic 
dressing,  either  several  folds  of  aseptic  gauze  or  one  of  the  aseptic  vulval  pads  in 
common  use.  This  dressing  is  allowed  to  remain  in  situ  until  the  placenta 
displaces  it  on  the  delivery  of  the  latter.  This  dressing  I  use  with  two  objects 
in  view:  first,  to  prevent,  as  far  as  possible,  the  entrance  of  air  into  the  gap- 
ing vagina;  and,  second,  to  indicate  the  amount  of  hemorrhage  going  on  at 
this  period. 


Fig.  633. — Temporary  Vulval 
Dressing  of  Sterile  Gauze 
DURING  the  Third  Stage  of 
Labor. 


MANAGEMENT  OF  THE  THIRD  STAGE  OF  LABOR. 

The  third  stage  of  labor  commences  at  the  complete  expulsion  of  the  fetus  01 
fetuses  and  ends  at  the  complete  expulsion  of  the  placenta  and  membranes.  The 
patient  having  been  carefully  assisted  in  turning  from  the  lateral  to  the  dorsal 
posture,  the  physician  or  nurse  continues  by  gentle  pressure,  not  kneading,  of  the 
fundus  to  Keep  up  and  encourage  firm  tonic  uterine  contractions  in  order  to  pre- 
vent hemorrhage  and  the  formation  of  an  intrauterine  clot.  When  the  uterus  does 


THE  MANAGEMENT   OF   LABOR.  .       491 

not  seem  to  be  doing  its  work  properly,  it  may  be  necessary  to  use  gentle  friction 
by  a  circular  motion  with  the  hand  until  contractions  are  resumed,  or  it  may 
even  be  necessary  to  grasp  the  fundus  vigorously  and  subject  it  to  active  manipu- 
lation in  order  to  get  a  prompt  response.  There  is  generally  a  tendency  to 
hasten  the  completion  of  the  third  stage.  This  should  be  avoided,  and  the 
temporary  suspension  of  strong  uterine  contractions  after  the  expulsion  of  the 
child  should  be  looked  upon  as  a  physiological  condition.  Common  mistakes 
at  this  time  are:  (i)  Undue  haste  and  rough  manipulation  in  the  completion  of 
the  third  stage.  This  is  a  common  cause  of  retained  placenta.  (2)  Premature 
attempts  at  expulsion.  It  should  be  delayed  at  least  until  about  half  an  hour 
after  the  birth  of  the  fetus  unless  previous  separation  occurs.  (3)  The  neglect 
to  assure  one's  self  that  the  bladder  is  empty.  (4)  To  press  the  uterus  forward 
against  the  pubis  instead  of  downward  and  backward,  more  in  the  axis  of  the 
pelvic  outlet.  (5)  To  excite  contractions  instead  of  waiting  for  the  natural 
ones.  The  former  method  should  be  practised  only  in  cases  of  hemorrhage  or 
dangerous  uterine  inertia.  (6)  It  is  not  necessary  to  twist  the  membranes  into  a 
rope,  and  sometimes  they  are  torn  in  this  way.  If  the  membranes  should  tear, 
a  piece  of  sterilized  thread  may  be  tied  to  the  part  projecting  from  the  cervix. 
Traction  upon  the  membranes  should  not  be  made. 

With  the  onset  of  the  third  stage  of  labor  care  as  to  asepsis  should  be  re- 
doubled. Untold  harm  has  been  done  by  unnecessary  interference  at  this  time, 
and  sepsis  is  often  caused  by  irrational  attempts  at  its  prevention.  After  the 
second  stage  the  vagina  and  cervix  are  full  of  abrasions  and  trifling  lacerations 
which  are  of  no  consequence  if  let  alone,  but  which  offer  a  tempting  field  for  the 
propagation  of  septic  germs.  In  normal  cases  all  manipulations  within  the 
vagina,  and  especially  the  introduction  of  the  fingers,  should  be  scrupulously 
avoided  during  and  after  the  third  stage  of  labor. 

Prevention  of  Hemorrhage  and  Delivery  of  Placenta  and  Membranes. — The 
chief  objects  at  this  time  are  (i)  to  secure  good  uterine  contraction,  (2)  to  pre- 
vent hemorrhage  and  to  deliver  the  placenta  and  membranes  intact.  If,  as  fre- 
quently happens,  the  placenta  follows  the  child  into  the  vagina,  it  may  be  ex- 
pressed at  any  time.  Usually,  however,  placental  separation  takes  at  least  half 
an  hour.  For  this  period  after  the  child  is  delivered  the  uterus  should  be  kept 
under  manual  observation,  and  if  the  placenta  and  membranes  are  not  expelled 
in  that  time,  the  Crede  method  may  be  resorted  to  (Figs.  634  and  635). 

Crede's  Method  of  Placental  Expression. — To  practise  this  the  fundus  is 
grasped  with  one  hand,  fingers  behind  and  thumb  in  front,  and  a  contraction 
awaited  (Fig.  636).  At  the  height  of  the  pain  the  uterus  is  firmly  compressed 
and  forced  downward  and  backward  into  the  pelvis.  If  the  first  attempt  fail, 
another  may  be  made  in  the  same  manner  at  the  next  contraction.  It  maybe 
necessary  to  repeat  this  procedure  during  several  contractions.  When  the  placenta 
appears  at  the  vulva,  little  or  no  traction  must  be  made  upon  it,  but  the  mem- 
branes loosened  and  expelled  by  compression  of  the  fundus  of  the  uterus,  at  the 
same  time  pushing  the  uterus  backward  as  nearly  into  the  axis  of  the  vagina  as 
possible ;  the  placenta  meanwhile  is  allowed  to  rest  in  the  palm  of  the  other  hand  so 
that  no  unnecessary  traction  shall  be  made  on  the  membranes  (Fig.  635).  The 
last  string  of  membrane  should  be  rather  squeezed  out  than  drawn  out.  After 
delivery  of  the  placenta  and  membranes  the  physician  continues  to  hold  the 
fundus  in  the  hand;  this  should  be  done  for  an  hour  after  deHvery  (Fig.  334)- 
An  assistant  or  a  nurse  may  relieve  the  physician  of  this  duty.  (See  Operations, 
Part  X.) 

Examination  of  the  Placenta  and  Membranes  (Fig.  637). — The  physician  now 


492 


PHYSIOLOGICAL   LABOR. 


takes  the  placenta,  turns  the  membranes  back,  and  places  the  fetal  surface  down 
on  the  palm  of  his  hand.  The  cotyledons  should  lie  in  close  apposition;  there 
should  be  no  defect  on  the  uterine  surface  at  the  furrows  limiting  the  cotyledons, 
or  at  the  margin  of  the  placenta;  the  grayish-white  coating  of  the  decidua  sero- 
tina  should  cover  the  cotyledons  and  no  red  placental  villous  tissue  should  be 
seen.      He  examines  the  margin  of  the  placenta  for  torn  vessels  pointing  to  the 

retention  of  the  secondary 
placenta  or  placenta  succen- 
turiata.  Then  he  passes  the 
hand  intq  the  cavity  of  the 
membranes,  distends  them, 
and,  taking  into  account  the 


Fig.  634. — Delivery  of  the  Placenta.  The  Left  Hand  follows  down  the  Fundus  of 
THE  Uterus  and  the  Right  Hand  Receives  the  Placenta,  the  Latter  Preventing 
any  Sudden  Tension  upon  the  After-coming  Membranes.  The  placenta  is  here  ex- 
pelled by  Schultze's  mechanism. — {From  a  photograph  taken  at  the  Emergency  Hospital.) 


size  of  the  child  and  the  amount  of  liquor  amnii,  estimates  as  nearly  as  possible 
whether  the  entire  bag  of  membranes  be  present. 

Retention  of  Secundines, — Retained  fragments  of  placenta  are  best  removed 
immediately  by  passing  two  fingers  into  the  vagina  and  os  uteri,  and  with  the 
external  hand  pressing  the  fundus  down  over  the  internal  fingers  which  grasp  and 
remove  the  fragments.  Dangers  of  subsequent  hemorrhage  and  sapremic  in- 
fection are  thus  avoided.     When  uncertainty  exists  regarding  the  retention  of 


THE  MANAGEMENT   OF  LABOR. 


493 


small  pieces  of  membrane,  one  can  safely  adopt  an  expectant  plan  of  treatment, 
as  in  this  case  it  is  safer  than  intrauterine  manipulations.  The  proposed  routine 
uterine  and  vaginal  examinations  of  the  genital  tract  at  this  time  to  determine 
the  condition  of  the  parts  and  the  retention  of  secundines  cannot  be  too  vigor- 
ously condemned.  Nothing  is  to  be  gained  by  this  course  save  in  very  excep- 
tional cases,  and  as  its  routine  practice  involves  a  distinct  element  of  risk,  its 
adoption  cannot  be  recommended. 


Fig.  635. — Delivery  of  the  Placenta.  The  Delivered  Placenta  is  Supported  in 
THE  Right  Hand  and  the  Left  Hand  Makes  Moderate  Pressure  upon  the  Fundus 
OF  THE  Uterus  until  the  Membranes  are  Loosened  and  Expelled. — {From  a 
photograph  taken  at  the  Emergency  Hospital.) 


Repair  of  the  Perineum. — Lacerations  of  the  vagina  and  perineum  should 
now  be  carefully  closed  with  appropriate  sutures.     (See  Part  X.) 

Ergot. — If  the  retraction  of  the  uterus  should  not  be  entirely  satisfactory  after 
it  is  emptied,  and  manipulations  and  the  Cred6  method  have  not  induced  contrac- 
tions, fluid  extract  of  ergot  may  be  given  by  the  mouth  or  subcutaneously.  The 
usual  dose  is  one-half  to  one  drachm  by  the  mouth  and  twenty  minims  hypo- 
dermically;  it  may  be  repeated  if  required.  This  drug  is  especially  useful  after 
chloroform  anesthesia,  since  the  uterus  sometimes  does  not  contract  quite 
promptly  after  its  employment.  Ergot  used  after  the  uterus  is  empty  is  useful 
as  a  preventive  not  only  of  hemorrhage,  especially  in  multiparae  and  atonic  cases, 


494 


PHYSIOLOGICAL   LABOR. 


but  of  sepsis,  and  as  an  aid  to  involution  and  in  the  prevention  of  after-pains. 
The  contraction  of  the  uterine  muscle  keeps  the  sinuses  closed,  preventing  the 


Fig.  636. — Crede's  Method  of  Placental  Expression. — {The  upper  illustration  is  from 
a  photograph  taken  at  the  Emergency  Hospital.) 

formation  of  clots  and  the  entrance  of  sepsis,  and  also  hastens  involution  by 
curtailing  the  blood-supply  to  the  uterine  muscular  tissue.     On  the  one  hand,  I 


THE  MANAGEMENT   OF   LABOR. 


495 


know  of  no  valid  objection  to  the  use  of  one  or  two  doses  of  ergot  after  confine- 
ment; and,  on  the  other,  the  drug  thus  used  adds  materially  to  the  safety  and 
comfort  of  the  patient. 

Post-partum  Douche. — There  is  at  present  some  controversy  as  to  the  advis- 
ability of  giving  a  vaginal  douche  after  delivery  of  the  placenta.  The  analogy 
between  the  indications  for  the  ante-partum  and  the  post-partum  douche  is  not, 
as  some  have  supposed,  perfect.  Before  delivery  the  vaginal  mucous  membrane 
is  intact  and  bathed  in  the  acid  bactericidal  mucus  of  the  vagina.  Hence,  as 
Kronig  has  shown  experimentally,  ante-partum  douches,  by  diluting  and  washing 
away  this  mucus,  actually  delay  the 
destruction  of  pathogenic  germs  pre- 
viously introduced  into  the  vagina. 
After  delivery  the  conditions  are  quite 
different  and  all  conditions  for  the  pro- 
pagation of  sepsis  are  present.  Hence 
it  seems  proper  that  one  thorough  vag- 
inal douche  should  be  given.  Nothing 
but  a  glass  tube  should  be  used,  and 
this  should  be  perforated  at  the  sides, 
the  perforations  looking  a  little  back- 
ward, that  the  fluid  may  not  enter  the 
uterus.  As  the  tube  is  introduced  the 
labia  should  be  carefully  separated 
(See  Part  X)  and  the  tube  carried 
as  far  as  possible  into  the  vagina  with- 
out touching  the  surrounding  tissues. 
When  few  or  no  vaginal  examinations 
have  been  made,  the  post-partum 
douche  should  be  omitted.  It  may  be 
said  to  carry  a  risk  of  infection  with 
it,  but  not  to  the  same  extent  as  the 
digital  vaginal  examination  (Figs.  192 
and  1 9  3 ) .  In  intelligent  hands  the  irri- 
gation is  practically  free  from  danger. 
It  certainly,  in  my  experience,  adds  to 
the  comfort  and  safety  of  the  patient : 
(i)  by  causing  the  uterus  and  vagina 
to  expel  retained  clots;  (2)  by  setting 
up  firm  uterine  contraction  which  pre- 
vents hemorrhage  and  after-pains;  (3) 
the  warmth  lessens  the  pain  of  the 
laceration  and  stretching  to  which  the 

vagina  has  been  subjected.  An  intrauterine  douche  is  given  only  when  the  hand 
or  instruments  have  been  introduced  into  the  uterus,  or  when  there  is  other 
reason  to  suspect  the  possibility  of  intrauterine  sepsis. 

Cleansing  of  the  Patient  and  Bed. — At  the  completion  of  the  third  stage  the 
external  genitals  should  be  carefully  cleansed  with  boiled  water  and  with  bichlo- 
ride solution  (i  :  4000);  the  cleansing  should  include  the  thighs,  buttocks,  and 
lower  surface  of  the  abdomen,  since  these  are  usually  soiled  by  blood,  perhaps 
by  urine  and  feces.  The  temporary  bedding  should  be  removed  and  its  place 
supplied  by  that  which  is  perfectly  clean,  and  the  patient  should  be  given,  if 
necessary,  a  clean  night-dress. 


Fig.  637. — InspectiOxV  of  Placenta  and 
Membranes  immediately  after  the 
Third  Stage.  Hand  is  Passed  into  Am- 
niotic Cavity  and  same  Distended  while 
Inspecting  the  Cotyledons  of  the  Pla- 
centa.—  {From  a  fresh  specimen.) 


496  PHYSIOLOGICAL   LABOR. 

Vulval  Dressing. — A  sterile  napkin,  preferably  an  antiseptic  pad  of  some 
absorbent  material,  should  be  applied  to  the  vulva  and  held  in  position  by  a 
band  carried  between  the  thighs  and  fastened  anteriorly  and  posteriorly  to  the 
abdominal  binder  by  safety-pins.  This  vulval  dressing  should  be  changed  as 
often  as  it  becomes  soiled.  Deodorizing  chemicals  or  those  with  any  odor 
should  not  be  used  on  the  vulval  dressing,  as  these  mask  the  fetor  of  decompos- 
ing lochia,  a  valuable  sign  of  early  septic  infection. 

Abdominal  Binder. — This  contributes  to  the  comfort  of  the  patient  and  is 
usually  desirable.  It  should  be  of  unbleached  muslin  and  wide  enough  to  reach 
from  below  the  trochanters  to  the  lower  ribs.  The  attendant  should  stand  on 
the  patient's  right  and  the  binder  should  be  fastened  from  below  upward.  This 
should  be  done  by  taking  the  part  of  the  binder  next  to  the  abdomen  in  the  left 
hand  and  the  part  which  is  to  be  external  in  the  right  and  holding  them  together 
with  one  hand  while  the  pins  are  inserted  from  below  upward  with  the  right 
hand.  A  moderately  tight  abdominal  binder  promotes  involution  of  the  uterus. 
After  a  few  days  it  may  be  applied  more  loosely,  but  may  be  discarded  when 
the  patient  leaves  her  bed.     (See  Part  VI.) 

Presence  of  the  Physician. — The  physician  should  be  within  call  for  at  least 
an  hour  after  the  completion  of  the  third  stage,  and  should  not  leave  his  patient 
until  good  uterine  contraction  has  been  secured  and  her  pulse  has  become  nor- 
mal, or  is  at  least  below  loo. 

Nourishment,  Rest,  and  Sleep. — When  the  third  stage  has  been  completed 
and  the  patient  made  comfortable,  she  should  receive  some  light  nourishment, 
as  a  cup  of  milk,  weak  tea,  chocolate,  cocoa,  or  soup.  All  visitors  should  be 
banished  from  the  lying-in  chamber;  the  curtains  should  be  drawn,  the  room 
well  ventilated,  and  the  patient  allowed  to  secure  as  much  sleep  as  possible, 
undisturbed  by  the  washing,  dressing,  or  crying  of  the  child. 


32 


PART    FIVE, 


Pathological   Labor* 


DUE  TO  ABNORMAL  CONDITIONS  OF  THE  FETUS:    FETAL 

DYSTOCIA, 

FETAL  DYSTOCIA  FROM  FAULTY  ATTITUDE.  (Page  499.)  I.  Excessive 
Flexion  of  Head.  Roederer's  Obliquity.  II.  Bregma  Presentation.  In- 
complete Flexion.  III.  Brow  Presentation.  IV.  Face  Presentation.  V. 
Presentation  of  Anterior  Parietal  Bone  or  Ear.  Naegele's  Obliquity.  VI. 
Presentation  of  Posterior  Parietal  Bone  or  Ear.  Litzmann's  Obliquity.  VII. 
Prolapse  of  the  Arms.  Dorsal  Displacement  of  the  Arm.  VIII.  Prolapse 
of  the  Leg.     IX.  Prolapse  of  the  Cord. 

FETAL  DYSTOCIA  FROM  FAULTY  PRESENTATION. 
Presentation.     XI.  Shoulder  Presentation. 


(Page  527.)     X.  Pelvic 


FETAL  DYSTOCIA  FROM  FAULTY  POSITION.  (Page  545.)  XII.  Persistent 
Occipito-Posterior  Position.  XIII.  Persistent  Mento-posterior  Position. 
XIV.  Transverse  Position  of  Head  at  Outlet. 

FETAL  DYSTOCIA  FROM  GENERAL  FETAL  CONDITIONS.  (Page  554.)  XV. 
Multiple  Birth.  XVI.  Multiple  or  Compound  Presentations.  XVII.  Ex- 
cessively Long  Cord.  XVIII.  Short  Cord.  XIX.  Rupture  of  the  Cord. 
XX.  Decapitation    of   the    Fetus.     XXI.  Avulsion    of    Fetal    Extremities. 

XXII.  Malformations,    Deformities,    and  Anomalies    Producing  Dystocia. 

XXIII.  Fetal  Rigor  Mortis. 

DUE  TO  ABNORMAL  CONDITIONS  IN  THE  MOTHER:   MA- 
TERNAL DYSTOCLA.. 


MATERNAL  DYSTOCIA  FROM  THE  FORCES.  (Page  567.)  I.  Precipitate  Labor. 
II.  Protracted  or  Retarded  Labor.     Uterine  and  Abdominal  Inertia. 

MATERNAL  DYSTOCIA  IN  THE  PARTURIENT  TRACT  AND  ADNEXA.  (Page 
574.)  III.  Retention  of  Placenta  and  Membranes.  IV.  Post=partum  Hemor- 
rhage. V.  Rupture  of  the  Uterus.  VI.  Inversion  of  the  Uterus.  VII.  Ex= 
cessive  Right  Lateral  Obliquity  of  Uterus.  VIII.  Rupture  of  Cervix,  Vagina, 
Rectum,  Perineum.  IX.  Labor  after  Anterior  Fixation  or  Suspension  of 
Uterus. 

MATERNAL  DYSTOCIA  FROM  OBSTRUCTED  LABOR.  (Page  602.)  X.  Uter- 
ine, Ovarian,  Renal,  Peritoneal  Tumors.  XI.  Anomalies  of  the  Membranes. 
XII.  Rigidity  of  the  External  and  the  Internal  Os.  Trismus  Uteri.  XIII. 
Deviation  or  Malposition  of  the  Os.  XIV.  Occlusion  of  the  External  Os. 
XV.  Cancer  of  the  Uterus.  XVI.  Rigidity  and  Atresia  of  the  Vagina  and 
Vulva.  XVII.  Vaginal  and  Vulval  Thrombosis  and  (Edema.  XVIII.  Dis- 
tended Bladder  and  Rectum.  Cystocele,  Rectocele,  Vesical  Calculus.  XIX. 
Fractures  of  the  Pelvis.  XX.  Diastasis  of  Pelvic  Joints.  XXI.  Pelvic 
Deformity. 

MATERNAL  DYSTOCIA  FROM  GENERAL  MATERNAL  CONDITIONS.  (Page 
665.)  XXII.  Labor  in  Elderly  Primiparae.  XXIII.  Intestinal  Hernias. 
XXIV.  Cardiac  and  Pulmonary  Disease.  XXV.  Cerebral  and  Spinal 
Disease.  XXVI.  Digestive  Disturbances.  XXVII.  Sudden  Death.  XXVIII. 
Post-mortem  Delivery.     XXIX.  The  Metrorrhagia  of  Labor. 


Pathological  labor  or  dystocia — the  latter  term  from  two  Greek  words 
meaning  difficult  or  painful  labor — is  one  which  departs  from  the  conditions  of 
physiological  labor,  as  set  forth  on  page  375.  A  multitude  of  variations,  acci- 
dental and  pathological,  may  arise  on  the  part  of  the  mother  or  the  fetus  to 
cause  this  variety  of  labor.  Originating  in  the  latter  they  cause  fetal  dystocia, 
and  in  the  former  maternal  dystocia. 

According  to  my  classification  I  shall  describe  fetal  dystocia  as  due  to: 
(i)  faulty  attitude;  (2)  faulty  presentation;  (3)  faulty  position;  and  (4)  general 
fetal  conditions.  Maternal  dystocia  I  divide  into  dystocia  from  (i)  the 
forces;  (2)  the  parturient  tract  and  adnexa;  (3)  obstructed  labor;  (4)  general 
maternal  conditions. 


DUE  TO  ABNORMAL  CONDITIONS  OF  THE  FETUS: 

FETAL   DYSTOCIA. 

FETAL  DYSTOCIA  FROM  FAULTY  ATTITUDE. 

Faulty  attitude  or  posture  of  the  fetus  may  be  caused  by  anything  which 
alters  the  normal  shape  of  the  fetal  ovoid  (see  page  421).  Thus,  dystocia  may 
be  due  to  a  faulty  attitude  caused  by  any  deviation  of  the  fetal  head  from  the 
normal  position  of  flexion.  According  to  the  degree  of  extension  present  will 
be  the  variety  of  the  malpresentation  which  will  result.  (i)  Thus,  occa- 
sionally excessive  flexion  (Fig.  638),  or  Roederer's  obliquity,  under  certain 
conditions  may  act  as  a  cause  of  fetal  dystocia.  (2)  If  the  flexion  is  incomplete 
to  a  slight  degree  only,  so  that  the  chin  departs  only  a  short  distance  from  the 
sternum,  the  bregma  will  present  instead  of  the  vertex  and  a  bregma  presentation 
results.  (3)  If  a  greater  degree  of  extension  occurs  and  the  head  occupies  a 
position  upon  its  transverse  axis,  midway  between  flexion  and  extension,  the 
brow  or  the  region  immediately  in  front  of  the  bregma  will  present,  giving  a 
brow  presentation.  (4)  And  if  complete  extension  take  place  and  the  chin  is 
the  presenting  part,  a  face  presentation  results.  (5)  Further,  should  lateral 
flexion  of  the  head  occur  so  as  to  cause  the  anterior  parietal  bone  or  the  ear  to 
present,  the  condition  known  as  Naegele's  obliquity  occurs.  (6)  Should  the 
lateral  flexion  result  in  presentation  of  the  posterior  parietal  bone  or  the  ear, 
the  obliquity  is  called  Litzmann's.  Faulty  attitude  may  also  result  in  prolapse 
of  the  (7)  arms,  (8)  legs,  (9)  umbilical  cord. 

I.  EXCESSIVE  FLEXION  OF  THE  HEAD;  ROEDERER'S  OBLIQUITY. 

Excessive  flexion  of  the  head  upon  the  trunk  has  been  termed  Roederer's 
obliquity  (Fig.  638).  This  is  nothing  more  than  an  exaggeration  of  the  normal 
head  flexion  of  labor  whereby  the  occiput  enters  the  inlet  perpendicularly,  the 

499 


500 


PATHOLOGICAL   LABOR. 


EXCESSIVE   FLEXION   OF    HEAD. 
ROEDERER'S  OBLIQUITY. 


Fig. 


head  moulding  being  more  to  the  posterior  part  of  the  head,  with  the  apex  well 
back  on  the  occipital  bone,  thus  positively  providing  for  the  engagement  of  the 
suboccipito-bregmatic  circumference,  ii  inches  (28  cm.),  in  the  circumference 
of  the  inlet,  16  inches  (40.5  cm.),  and  is  to  be  looked  upon  as  a  favorable  condi- 
tion. The  causes  are  excessive  rigidity  of  the  cervix  or  vagina,  generally  con- 
tracted pelvic  inlets,  or  excessively  large 
fetal  heads,  especially  in  dead  or  macer- 
ated fetuses.  The  diagnosis  is  simple.  In 
left  positions  of  the  head  the  small  fon- 
tanelle  is  more  to  the  right  and  very  little 
of  the  sagittal  suture  can  be  felt ;  the  large 
fontanelle  is  unusually  high.  The  prognosis 
is  not  necessarily  favorable  at  the  pelvic 
inlet,  although  after  the  engagement  of  the 
head  the  conditions  never  cause  dystocia. 
Because  of  the  obstruction  sometimes  pro- 
duced at  the  inlet  by  excessive  flexion  of  a 
large  head  of  a  dead  or  macerated  fetus, 
causing  the  shoulders  and  head  to  attempt 
to  enter  at  the  same  time,  I  have  classed 
this  condition  among  the  causes  of  fetal 
dystocia.  Many  authorities  refer  to  the 
condition  only  \mder  normal  labor.  Treat- 
ment may  be  demanded  at  the  inlet  to 
assist  in  the  engagement  of  the  head,  since 
the  tonicity  of  the  neck  has  been  lost  in 
macerated  fetuses.  After  engagement  no 
treatment  is  required. 

II.    BREGMA     PRESENTATION.*       IN- 
COMPLETE FLEXION. 

Definition. — By  this  condition  is  meant ' 
a  partial  extension  of  the  head  whereby 
the  large  fontanelle  is  brought  upon  the 
same  plane  as  the  small  (Fig.  641). 

Frequency. — Authorities  generally  state 
that  incomplete  flexion  resulting  in  a 
bregma  presentation  is  rare.  My  experi- 
ence is  that  dystocia  from  this  source  is 
most  common.  I  believe  it  to  be  one  of 
the  most  important  factors  in  the  produc- 
tion of  prolonged  and  tedious  labors,  either 
from  tardiness  in  the  rotation  from  a  pos- 
terior to  an  anterior  position  due  to  the 
incomplete  flexion,  or  because  the  occipto- 
frontal  circumference  (13!  inches — 35  cm.) 
instead  of  the  suboccipito-bregmatic  (11  inches — 28  cm.)  is  brought  in  rela- 
tion to  the  periphery  of  the  birth  canal. 

Temporary  and  Persistent  Varieties. — A  close  observer  cannot  fail  to  detect 
instances  in  which  incomplete  flexion  of  the  head  or  bregma  presentation  has 

*  The  bregma  is  the  anterior  fontanelle. 


638. — Occiput   at   the    Pelvic 

Inlet. 


Fig 


639. — Occiput    at   the    Pelvic 
Inlet. 


Fig.    640. — Occipital    Bone    in    the 
Cervix. 


FETAL   DYSTOCIA    FROM   FAULTY  ATTITUDE. 


501 


BREGMA    PRESENTATION     OR    IN- 
COMPLETE FLEXION  OF 
THE  HEAD. 

Vertex  to  the  Left. 


(f 


f 


occurred  both  as  a  temporary  and  as  a  persistent  condition.  Temporary  descent 
of  the  large  fontanelle  is  frequently  observed  in  all  the  four  positions  of  the  vertex 
in  normal  labors  during  the  engagement  of  the  head  in  the  inlet,  but  more  fre- 
quently in  roomy  pelves  after  the  head  has 
passed  the  psoas  muscles  and  entered  the 
roomier  part  of  the  pelvis,  also  in  slightly 
and  decidedly  flattened  pelves  in  conjunc- 
tion with  Naegele's  lateral  flexion  and 
presentation  of  the  anterior  parietal  bone. 
In  the  case  of  flattened  pelves  the  biparie- 
tal  diameter  becomes  arrested  at  the  con- 
tracted inlet,  the  narrower  bitemporal 
diameter  of  the  sinciput  descends,  engages, 
and  passes  the  inlet,  followed,  after  a 
period  of  moulding,  by  the  biparietal  and 
restitution  of  the  head  to  its  normal  state 
of  complete  flexion.  In  the  persistent 
variety,  although  the  same  etiological  fac- 
tors may  obtain,  still  for  some  reason  the 
condition  becomes  permanent. 

Etiology. — This  is  the  same  as  in  brow 
and  face  presentations,  although  in  some 
instances  dolichocephalic  conditions  of  the 
fetal  head  play  an  important  part  (pages 
503  and  509). 

Positions  '  and  Relative  Frequency. — 
The  positions  and  their  relative  frequency 
are  the  same  as  in  vertex  presentations, 
as  the  anatomical  conditions  differ  very 
little  from  those  of  normal  labor. 

Mechanism. — While  some  authorities 
consider  that  bregma  presentation  demands 
a  description  of  a  special  mechanism,  I  am 
accustomed  to  describe  the  condition  as 
merely  a  departure  from  the  mechanism  of 
vertex  presentation  due  to  moderately 
incomplete  flexion  of  the  head.  The  me- 
chanism differs  from  that  of  normal  vertex 
presentation  in  that  departure  from  the 
normal  occurs  by  reason  of  the  increased 
circumference  of  the  presenting  part,  and, 
further,  the  imperfect  flexion  brings  the 
forehead  down  as  far  as  the  vertex,  thus 
interfering  with  internal  anterior  rotation. 
It  must  be  remembered  that  labor  is  not 
impossible  in  all  cases  of  this  condition, 
and  that  the  several  steps  in  the  mechanism 
can  be  recognized  as  in  other  presenta- 
tions. Should  the  partial  extension  be 
follows:  Moulding  is  extensive  by  reason 
frontal  diameter  (4.5    inches — 11.50    cm.) 


^FlG.    641. 


-Bregma    at 
Inlet. 


THE  Pelvic 


Fig. 


-Bregma  at 
Inlet. 


THE    Pelvic 


Fig.  643. — In  the  Cervix.-  Right 
Parietal  Bone  and  Halp^  of 
Frontal  Presenting. 


uncorrected,  the  mechanism    is  as 

of  the  delay.     Since  the  occipito- 

and    circumference  (13!  inches — 35 


cm.),  and  not  the   suboccipito-bregmatic  diameter   (3f  inches — 9.5  cm.)    and 


502 


PATHOLOGICAL   LABOR. 


BREGMA  PRESENTATION  OR  INCOM- 
PLETE FLEXION  OF  THE  HEAD, 

VERTEX  TO  THE  RIGHT. 


I   i 

Fig.  644. — Bregma  at  the  Pelvic  Inlet. 


Fig.  645. — Bregma  at  the  Pelvic  Inlet. 


Fig.  646. — In  the  Cervix:  Left  Parie- 
tal Bone  and  Half  of  Frontal  Pre- 
senting. 


Fig.  647. — At  the  Pelvic  Floor, 


circumference  (11  inches — 28  cm.),  are 
brought  in  relation  with  the  diameters 
and  circumference  of  the  pelvic  inlet, 
persistent  bregma  presentations  undergo 
prolonged  and  characteristic  moulding 
(Fig.  649).  Engagement  and  descent  are 
slow  by  reason  of  the  greater  circumfer- 
ence involved ;  rotation  of  the  head  fails 
altogether  because  the  vertex  and  fore- 
head are  equally  influenced  by  the  factors 
causing  rotation,  or  is  accomplished  only 
with  the  greatest  difficulty  and  much 
damage  to  the  maternal  soft  parts. 
Labor  often  comes  to  a  standstill  by 
reason  of  the  transverse  position  of  the 
occipito-frontal  diameter  on  the  pelvic 
floor.  The  perineum  begins  to  tear  even 
before  the  head  has  reached  it,  on 
account  of  the  great  dilatation  of  the 
upper  vagina  by  the  large  cephalic 
diameters.  The  laceration  becomes  ex- 
tensive, extending  through  the  sphincter 
ani  and  even  up  the  recto-vaginal  sep- 
tum. In  expulsion  of  the  head  the 
latter  is  bom  by  propulsion  and  partial 
extension.  Rotation  and  delivery  of 
the  trunk  occur  as  in  normal  labor. 

Diagnosis. — This  is  not  difficult. 
Whenever  on  vaginal  examination  the 
large  fontanelle  is  readily  made  out  as 
occupying  a  prominent  place  in  the  cir- 
cumference of  the  parturient  canal  with 
the  sagittal,  frontal,  and  coronal  sutures 
radiating  therefrom,  the  condition  may 
be  looked  upon  as  one  of  bregma  presen- 
tation or  incomplete  flexion  of  the  head. 
This  presentation  in  its  clinical  features 
resembles  a  brow,  as  the  supraorbital 
ridges  may  often  be  palpated  well  up 
anteriorly,  posteriorly,  or  laterally. 
(Figs.  646  and  642.) 

Prognosis. — This  is  usually  good,  as 
the  condition  is  readily  recognized  and 
remedied.  When  overlooked,  all  the 
dangers  of  tedious  labor  and  secondary 
inertia  are  to  be  feared. 

Treatment. — Immediate  correction  of 
the  incomplete  flexion  should  be  made 
either  (i)  by  pushing'  the  forehead 
up  during  uterine  contraction  with 
two  fingers  in  the  vagina,  at  the  same 
time  making  pressure  upon  the  fundus; 


FETAL  DYSTOCIA   FROM   FAULTY   ATTITUDE. 


603 


MOULDING    OF    HEAD    IN 
PRESENTATION. 


BREGMA 


Fig.  648. — Before  Moulding. 


or  (3)  the  whole  hand  may  be  introduced  into  the  vagina  and  either  the  occiput 
drawn  down  or  the  forehead  pushed  up,  counterpressure  being  at  the  same  time 
made  upon  the  podalic  extremity  of  the 
fetus  through  the  fundus,  or  upon  the 
occiput  through  the  lower  uterine  seg- 
ment. (See  Correction  of  Bregma, 
Brow,  and  Face  Presentations,  Part  X.) 

III.  BROW  PRESENTATION. 

Definition. — A  partial  extension  of 
the  head  whereby  the  brow  instead  of 
the  vertex  becomes  the  presenting  part. 
The  head  is  so  extended  in  this  presen- 
tation as  to  occupy  a  position  midway 
between  complete  flexion  and  complete 
extension  (Fig.  650). 

Frequency. — This  is  the  rarest  of  all 
cephalic  presentations  and  occurs  in 
one-fourth  of  one  per  cent,  of  all  cases. 
As  brow  presentation  is  a  transition 
stage  in  the  development  of  face  pre- 
sentation, it  is,  considered  temporarily, 
as  frequent  as  the  latter.  But  as 
generally  estimated — those  which  re- 
main brow  till  artificially  altered — they 
are  far  less  common  than  the  face.  In 
a  series  of  2200  consecutive  confine- 
ments I  found  brow  presentation  in  3 
cases,  or  0.13  per  cent.,  or  i  in  733  cases. 
Face  presentation  occurred  in  5  cases,  or 
0.22  per  cent.,  in  the  same  series. 

Etiology. — Any  cause  which  favors 
incomplete  flexion  or  partial  extension 
of  the  head  may  cause  a  brow  presenta- 
tion; the  causes  are,  therefore,  the  same 
as  those  for  face  presentation.  (See  page 
509.)  If  the  brow  is  not  converted  by 
natural  means  into  a  face  presentation, 
the  inference  must  be  drawn  that  there 
is  a  greater  obstacle  present  than  in 
cases  in  which  face  presentation  de- 
velops. The  forces  exerted  on  the  two 
arms  of  the  head-lever  in  brow  presenta- 
tion are  almost  equal,  the  posterior  arm 
being  just  a  little  longer  than  the  ante- 
rior (Fig.  648). 

Positions  and  Relative  Frequency. — There  are  four  cardinal  positions  of  the 
brow,  as  in  other  presentations: 


Fig.   649. — After  Moulding. 


I.   Left  fronto-anterior — Fronto  Lasva  Anterior — L.  F.  A.  (Fig.  650). 
II.  Right  fronto-anterior — Fronto  Dextra  Anterior — R.  F.  A. 


504 


PATHOLOGICAL   LABOR. 


FIRST  BROW  POSITION. 
LEFT  FRONTO-ANTERIOR,  L.  F.  A. 


III.  Right   fronto-posterior — Fronto 
Dextra  Posterior — R.  F.  P. 

IV.  Left     fronto-posterior  —  Fronto 
Laeva  Posterior — L.  F.  P.  (Fig.  654). 


Fig.  650. — Brow  at  Pelvic  Inlet. 


Fig.  651. — Brow  in  the  Cervix. 


As  in  vertex  presentation,  the  third 
and  first  positions  are  the  most  frequent, 
and  in  the  order  named. 

Mechanism. — (i)  Brow  presentation, 
being  often  a  transitional  condition 
between  vertex  and  face  presentation, 
may  at  any  stage  in  the  mechanism  of 
labor  be  converted  into  one  of  these 
spontaneously.  (2)  Again,  with  a  roomy 
pelvis  and  a  small  fetus,  the  latter 
in  brow  presentation  may  be  pushed 
through  the  pelvis  without  any  special 
mechanism.  (3)  In  exceptional  cases 
in  "^hich  the  fetal  head  is  relatively 
small,  special  mechanisms  of  brow  pres- 
entation can  be  recognized,  as  follows: 

III.  Right  Fronto-posterior,  R. 
F.  P. — (i)  Moulding:  This  process  is 
so  slow  that  sometimes  labor  pains 
continue  for  hours — twenty-four  to 
thirty-six — before  engagement  of  the 
brow  takes  place.  In  the  unusual  cases 
in  which  a  brow  presentation  enters  the 
pelvis,  there  has  been  an  extreme  mould- 
ing of  the  head,  the  latter  being  rather 
small;  the  caput  succedaneum  occupies 
the  space  from  the  root  of  the  nose  to 
the  anterior  fontanelle.  A  side  view  of 
the  head  shows  it  to  be  rather  triangu- 
lar in  shape.  (See  Figs.  659  and  660.) 
Fig.  652. — At  _Pelvic  Floor  before  The  occipito-mental  diameter  has  de- 
creased, but  this  has  been  compensated 
for  by  an  increase  of  the  occipito-fron- 
tal.  The  shape  of  the  head  is  now 
characteristic  of  this  presentation.  The 
slope  of  the  parietal  and  occipital  bones 
is  downward  and  backward,  while  the 
forehead  is  almost  perpendicular.  (2) 
Engagement  and  Descent:  Because  of  the 
altered  shape  of  the  head  the  forehead 
sinks  into  the  pelvis  more  deeply  than 
any  other  part  of  the  head  and  the 
head  is  somewhat  extended  as  it  passes 
through  the  pelvic  inlet.  The  course 
of  the  brow  to  the  pelvic  floor  is 
due   to    energetic   contractions   of    the 


Anterior  Rotation  of  Brow. 


Fig.  653. — In    the  Vulva    after  Ante- 
rior Rotation  of  the  Brow. 


uterus,  causing  the  mother  much  pain. 


FETAL   DYSTOCIA   FROM   FAULTY   ATTITUDE. 


505 


Labor  usually  comes  -to  a  standstill 
at  this  stage  of  engagement  and  de- 
scent by  reason  of  obstruction.  (3) 
Anterior  Rotation  of  the  Forehead  (Fig. 
656):  If  the  presentation  remains  un- 
changed until  expulsion,  the  forehead 
finally  reaches  the  pelvic  floor  and 
rotates  anteriorly  for  the  same  reasons 
as  the  occiput  does  in  vertex  presenta- 
tion. At  the  same  time  the  vertex  ro- 
tates posteriorly  into  the  hollow  of  the 
sacrum.  The  brow  lies  opposite  the 
vulva,  the  face  just  back  of  the  pubis 
with  the  chin  at  its  upper  margin,  and 
the  superior  maxilla  against  the  sym- 
physis. Anterior  rotation  of  the  brow 
at  the  pelvic  floor  may,  in  exceptional 
cases,  possibly  occur,  but  more  often 
labor  comes  to  a  standstill  with  a 
deep  transverse  position  of  the  head. 
(4)  Expulsion  of  the  Head  (Fig.  657): 
Before  the  head  has  appeared  outside 
the  vulval  orifice,  the  neck  and  the 
body  of  the  child  have  descended  some- 
what into  the  pelvis.  The  flexion  of 
the  head  is  increased  as  the  forehead 
appears  in  the  vulva;  the  perineum 
then  retracting.  Expulsion  is  accom- 
plished by  the  cranial  vault  first  sweep- 
ing forward  over  the  perineum ;  then  the 
eyes,  nose,  superior  maxilla,  mouth,  and 
chin  successively  make  their  appearance 
under  the  symphysis  pubis,  and  are 
bom.  (5)  Rotation  of  the  Trunk  and 
Restitution  of  the  Head  (Figs.  653  and 
657):  After  delivery  of  the  head,  shoulder 
rotation  and  restitution  of  the  head 
occur  as  in  vertex  presentation.  In 
the  right  fronto-posterior  position  the 
left  shoulder  rotates  to  the  symphysis 
and  restitution  of  the  child's  face  to  the 
left  thigh  occurs.  (6)  Expulsion  of  the 
Trunk:  This  is  the  same  as  in  vertex 
and  face  presentations  (page  447)- 

I,  II,  and  IV.  Left  Fronto-ante- 
RiOR,  L.  F.  A.;  Right  Fronto-ante- 
RioR,  R.  F.  A.:  AND  Left  Fronto- 
posterior,  L.  F.  P.  (Fig.  654),  follow 
the  same  general  principles  as  the 
above. 

Persistent  Posterior  Rotation  of  the 
Brow. — As   in   permanent  occipito-pos- 


FOURTH  BROW  POSITION. 
LEFT  FRONTO-POSTERIOR,  L.  F.  P. 


Fig.  654. — Brow  at  Pelvic  Inlet. 


Fig.  655. — Forehead  in  the  Cervix. 


?5>^x 


:  l^-  ^ 


•j^ 


Fig.  656. — Brow  at  the  Pelvic  Floor 
BEFORE  Anterior  Rotation  of-  thb 
Forehead. 


^         ^  ,. O 


Fig.  657. — Delivery  of  the  Head  after 
Anterior  Rotation  of  the  Brow. 


506 


PATHOLOGICAL   LABOR. 


tenor  and  mento-posterior  positions,  arrest  may  occur  at- the  pelvic  inlet,  or 
after  engagement  of  the  brow.  As  in  face  presentation  with  the  chin  posteriorly, 
the  difficulties  of  spontaneous  delivery  are  so  great  that  birth  may  be  said  to  be 
impossible  unless  anterior  rotation  of  the  brow  occurs. 


Position  of  Fetus. 


Position  of  Fetal  Heart 
Sounds. 


Left  fronto-ante- 
rior.     L.  F.  A. 


Brow  to  left  acetabulum;    back  to  right;  ex- 
tremities to  left,  above. 


Right    fronto-an- 
terior.    R.  F.  A. 


Right  fronto-pos- 
terior.  R.  F.  P. 

Left     fronto-pos- 
terior.    L.  F.  P. 


Brow  to  right  acetabulum;  back  to  left;  ex- 
tremities to  right,  above. 


Right  side  of  abdomen, 
below  umbilicus. 

Left  side  of  afedomen, 
bel«w  umbilicus. 


Brow  to  right  sacro-iliac  joint;    back  to  left; 
extremities  to  right,  above. 

Brow  to  left  sacro-iliac  joint;   back  to  right; 
extremities  to  left,  above. 


Left  side  of  abdomen, 
below  umbilicus. 

Right  side  of  abdomen, 
below  umbilicus. 


Diagnosis. — By  abdominal  examination  the  two  ends  of  the  head  may  be 
discovered  to  be  at  about  the  same  level  (Fig.  654).  Unless  the  subject  is  readily 
palpated,  the  diagnosis  of  a  brow  presentation  by  external  palpation  is  very 

difficult.  By  vaginal  ex- 
amination the  small  fon- 
tanelle  and  the  orbital 
ridges  are  felt  at  opposite 
points  in  the  available 
space,  while  the  large  f on- 
tan  elle  and  the  coronal, 
frontal,  and  sagittal  sutures 
are  between  (Figs.  651  and 

655)- 

Prognosis. — This  is  un- 
certain for  the  mother  and 
very  bad  for  the  fetus. 
Maternal  mortality  is  as 
high  as  10  per  cent.;  fetal 
mortality  has  reached  30 
per  cent.  The  dangers  to 
the  mother  are  exhaustion 
from  prolonged  labor  due 
to  obstruction,  severe  laceration  of  the  parturient  canal,  sepsis,  and  shock.  The 
dangers  to  the  child  are  excessive  moulding  and  compression  of  the  skull,  causing 
apoplexy  or  asphyxia;  prolapse  of  the  cord  is  a  common  complication,  as  in 
deformed  pelves,  because  the  brow  imperfectly  fits  the  pelvic  inlet.  The  family 
must  be  warned  that  the  child's  face  will  be  swollen  and  hideous  as  in  face  pres- 
entation. It  is  quite  possible  for  spontaneous  rectification  of  a  brow  presenta- 
tion to  occur  at  any  stage  of  the  mechanism  of  labor.  This,  however,  cannot  be 
relied   upon   any   more   than   in   shoulder  presentation.*     Sometimes,   though 

*  Ahlfeld  ("Die  Entstehung  Steiss-  und  Gesichtslagen  ")  furnishes  twenty-six  cases  in 
which  the  result  to  both  mother  and  child  is  given.  Fritsch  ("  Klinik  der  alltaglichen 
geburtshulflichen  Operationen,"  p.  46)  gives  the  histories  of  seven  cases,  and  Budin  ("Tete 
du  Foetus,"  p.  53)  the  history  of  one  case.  In  the  thirty-four  deliveries  there  were  two 
maternal  deaths;  in  one  of  the  fatal  cases  a  coxalgic  oblique  pelvis  existed  as  a  complica- 
tion. In  the  other  the  brow  spontaneously  changed  into  a  face  presentation.  There  were 
ten  spontaneous  deliveries,  the  brow  presenting  with  four  dead  children,  but  one  died 
previous  to  labor.     There  were  ten  cases  of  spontaneous  delivery  in  which  the  brow  during 


Fig.  658. — Persistent  Posterior  Position  of  the 
Brow. 


FETAL  DYSTOCIA   FROM  FAULTY  ATTITUDE. 


507 


rarely,  if  the  fetus  is  very  small,  or 
the  pelvis  very  large,  the  fetus  may 
be  delivered  without  any  mechanism 
or  danger.  In  reality  the  prognosis 
will  depend  on  the  operation  which  is 
chosen  for  delivery  of  the  child.  An 
unchanged  brow  position  with  normal 
head  will  require  so  much  time  for 
spontaneous  delivery  that  the  ob- 
stetrician cannot  conscientiously  wait 
for  nature  to  complete  the  birth. 

Treatment. — One  must  never  trust 
to  spontaneous  rectification;  manual 
correction  of  the  faulty  attitude  into 
a  vertex  presentation,  or  even  into  a 
breech  by  podalic  version,  gives  better 
results  than  waiting  for  spontaneous 
delivery  with  the  brow  presenting. 
Correction  of  a  brow  presentation  by 
changing  the  posture  of  the  woman, 
and  also,  I  may  add,  by  external 
manipulation  alone,  as  in  Schatz's 
method  (Part  X),  are  refinements  of 
obstetric  procedure  which  rarely  suc- 
ceed and  unnecessarily  disturb  the 
patient.  Further,  in  this  as  in  other 
faulty  attitudes,  presentations,  or 
positions  of  the  head  when  the  fetus  is 
positively    determined    to    be    dead. 


MOULDING   IN   BROW  PRESENTATION. 


Fig.  660. — Fetal  Skull  showing  Mould- 
ing IN  Brow  Presentation. — (Author's 
collection.) 


Fig.  659. — Before  Moulding. 


Fig.     66r. 


-After    Moulding    in    Fronto- 
Anterior  Position. 


delivery  became  converted  into  either  a  face  or  a  vertex  presentation.  Of  these  one  child 
died.  Fourteen  children  were  extracted  with  forceps,  nine  with  the  brow  presenting,  of 
which  two  were  dead,  one  from  prolapsed  funis,  and  one  which  had  died  before  labor;  five 
after  conversion  into  face  or  vertex  presentations,  with  no  deaths.  Thus  among  the  thirty- 
four  children  there  were  seven  deaths,  but  of  these,  four  only  could  be  attributed  to  the 
presentation. 


508  PATHOLOGICAL   LABOR. 

perforation  of  the  skull  and  extraction  with  the  cranioclast  or  cephalotribe  should 
always  be  performed  when  by  so  doing  the  prognosis  for  the  mother  is  improved. 
Arguments  from  the  standpoint  of  sentiment  alone  should  never  deter  us  from 
mutilating  the  head  of  a  dead  fetus  in  order  to  lessen  the  dangers  of  extracting 
an  unmutilated  head  through  the  birth  canal. 

1.  Before  Engagement  of  the  Brow. — (i)  Placing  the  parturient  on  the  side 
toward  which  the  dorsal  plane  of  the  fetus  points,  or  an  attempt  at  manual 
correction  by  external  manipulation  by  Schatz's  method  (see  Part  X),  may 
be  tried,  but  it  offers  little  hope  of  success.  (2)  Manual  conversion  of  the 
brow  into  a  vertex  by  combined  internal  and  external  methods  is  the  best 
treatment.  Digital  upward  pressure  on  the  brow ;  lifting  up  the  brow  with  the 
whole  hand;  drawing  down  upon  the  occiput  with  the  whole  hand,  or  one  of 
these  methods  combined  with  Schatz's  method,  and  all  combined  with  external 
manipulation,  as  described  in  Part  X,  should  be  tried,  and  in  the  order  named. 
Flexion,  once  obtained,  must  be  maintained  until  engagement  takes  place,  other- 
wise the  brow  presentation  will  recur.  These  indications  obtain  at  the  pelvic 
inlet,  in  both  fronto-anterior  and  fronto -posterior  positions  of  the  brow.  Of 
course,  the  conversion  of  the  former  into  a  vertex  presentation  results  in  an 
occipito-posterior  position  at  the  inlet,  but  even  this  position  of  the  vertex  offers 
a  better  prognosis  than  a  brow  presentation.  To  extend  the  head  manually 
in  fronto-anterior  positions  and  convert  the  brow  presentation  into  a  mento- 
anterior position  of  the  face,  is  a  most  questionable  procedure;  and  in  view  of 
the  serious  prognosis  in  face  presentations,  I  would  be  unwilling  to  recommend 
it.  Salowieff,*  however,  in  18  brow  cases  occurring  in  the  Moscow  Maternity 
Hospital  during  a  period  of  ten  years,  found  that  10  were  terminated  by  version 
and  expression,  i  by  forceps,  i  spontaneously,  i  in  a  vertex  presentation,  and 
5  in  face  presentations.  The  last  five  were  treated  by  introducing  a  finger  into 
the  child's  mouth,  drawing  the  chin  toward  the  brow,  and  retaining  the  finger 
in  the  mouth  until  the  uterine  contractions  fixed  the  head  in  the  converted  face 
presentation.  Simplicity  and  safety  are  claimed  for  this  procedure.  The  un- 
favorable prognosis  of  face  presentation  has,  however,  still  to  be  met.  (3)  The 
forceps  in  a  true  brow  presentation  should  never  be  resorted  to  before  at  least 
partial  rectification  of  the  faulty  attitude,  for  the  unusually  large  circumference 
of  the  presenting  part  results  disastrously  for  the  fetus  and  mother.  (4)  Fail- 
ing in  manual  rectification,  one  of  the  methods  of  version,  followed  promptly 
by  extraction,  offers  the  best  prognosis,  always  provided  the  necessary  con- 
ditions for  version  are  present  or  can  be  secured.     (See  Part  X.) 

2.  After  Engagement  of  the  Head. — (i)  An  attempt  at  manual  rectification 
as  described  above  should  be  made.  (2)  The  use  of  the  forceps  is  dangerous 
and  difficult,  and  must  only  be  tentatively  attempted.  (3)  Symphyseotomy, 
undoubtedly,  in  the  presence  of  a  living  fetus,  offers  the  only  hope  after  manual 
rectification  fails,  and  should  be  seriously  considered.  (4)  In  all  instances  in 
which  the  fetus  is  known  to  be  dead,  perforation  of  the  head  should  be  per- 
formed. 

IV.    FACE   PRESENTATION. 

Definition. — ^A  face  presentation  may  be  defined  as  a  cephalic  presentation 
in  which  the  head  is  in  extreme  extension,  with  the  occiput  in  contact  with  the 
neck.  The  face  engages  in  the  pelvis  with  the  chin  as  the  most  dependent  por- 
tion. Face  positions  are  therefore  classified,  in  accordance  with  the  location  of 
the  chin,  as  right  and  left  mento-anterior  and  posterior  (Figs.  663,  667,  671,  675). 
*  "  Centralbl.  f.  Gynak.,"  Leipzig,  1898,  No.  30. 


FETAL  DYSTOCIA    FROM   FAULTY   ATTITUDE. 


509 


Frequency. — About  .i  labor  in  250  is  a  face  presentation  (0.5  per  cent.). 
This  represents  an  average,  as  individual  statistics  show  considerable  variations. 
In  2200  cases  of  labor  I  found  that  face  presentation  occurred  in  5  cases,  or  0.22 
per  cent.,  or  i  in  440  cases  (Fig.  662).     (Compare  Pelvic  Deformity.) 

Etiology. — At  first  sight  face  presentation  appears  to  be  a  simple  anomaly 
of  the  mechanism  of  labor,  the  result  of  some  obstruction  in  the  parturient  tract 
which  unflexes  and  extends  the  head.  Regarded  from  this  simple  point  of  view, 
a  face  presentation  would  be  looked  upon  as  a  consequence  of  pelvic  contraction, 
and  perhaps  of  rigid  os,  prominent  ischial  spine,  and  the  like.  But  this  assump- 
tion is  by  no  means  easy  of  demonstration,  nor  is  there  any  necessary  ratio 
between  the  frequency  of  particular  types  of  obstruction  of  the  birth  tract  and 
deflexion  anomalies.  Some  other  factors  must  contribute  to  its  production. 
Both  observation  and  theory  point  to  the  possibility  that  anomalies  in  the  fetal 
head  or  neck  are  often  concerned  in  the  production  of  this  presentation.  Some 
of  the  conditions  which  reside  in  the  fetus  and  interfere  with  normal  flexion  are: 
congenital  goitre,  spastic 
contraction  of  the  muscles 
of  the  neck,  coiling  of  the 
cord  about  the  neck,  etc. 
But  conditions  of  this  sort 
occur  with  too  great  infre- 
quency  to  account  for  the 
production  of  face  presen- 
tation. Moreover,  the  fac- 
tors thus  far  enumerated 
do  not  account  for  all  the 
face  births  encountered  in 
practice,  or  even,  accord- 
ing to  some  authorities,  for 
the  majority  of  them.  We 
have  to  look  upon  face 
presentation  as  something 
more  than  an  anomaly  of 
the  mechanism  of  labor ;  or, 
in  other  words,  it  must  be 
placed  in  the  same  cate- 
gory with  breech  and  shoul- 
der presentations.  From  this  point  of  view  we  are  able  to  add  to  our  etiological 
factors  the  causes  of  malposition  in  general ;  including  prematurity,  contracted 
pelvis,  hydramnios,  multiple  pregnancy,  monstrosities,  etc.  These,  however, 
cannot  be  brought  into  direct  relationship  with  the  effects  produced,  and 
the  connection  between  the  two  is  a  matter  of  statistics  rather  than  of 
actual  demonstration.  It  is  evident  that  we  must  look  still  more  deeply 
into  the  matter  before  we  can  exhaust  all  possible  etiological  factors.  Only 
one  element  remains  for  consideration,  viz.,  the  uterus  itself.  Matthews  Duncan 
was  able  to  trace  a  relation  between  lateral  deviation  of  the  uterus  and  certain 
face  births;  and  other  authorities  have  similarly  held  the  triangular  and 
saddle-shaped  types  of  uterus  responsible  for  the  latter  in  certain  cases.  The 
individual  causal  elements  which  are  at  present  recognized  by  most  authorities 
may  be  divided  as  follows:  (i)  Causes  of  malposition  in  general,  such  as  pre- 
maturity, contracted  pelves,  hydramnios,  twin  pregnancy,  monstrosities,  etc., 
and   the    conditions    covered    by    Schatz's    hypothesis.      (2)    Causes    residing 


Fig.  662. 


Diagram  shqwing  the  Frequency  of  Face 
Positions. 


510 


PATHOLOGICAL   LABOR. 


FIRST  FACE  POSITION. 
LEFT  MENTO-ANTERIOR,  L.  M.  A. 


Fig.  663. — Face  at  Pelvic  Inlet. 


Fig.  664. — Chin   and   Left  Cheek  in 
THE  Cervix. 


r< 


\ 


Fig.  665. — Face  at  Pelvic  Floor 
before  Anterior  Rotation  of  the 
Chin. 


^a'J-y-''^^? 


Fig.  666. — Face  in  the  Vulva  after 
Anterior  Rotation  of  the  Chin. — 
{Author's  photograph.) 


in  the  uterus,  such  as  lateral  obliquity,  tri- 
angular and  saddle-shaped  uteri,  pendulous 
abdomen  (Fig.  151),  etc.  (3)  Causes  resid- 
ing in  the  fetus  which  interfere  with  flexion 
or  favor  extension.  These  are  numerous 
and  varied  and  include:  large  head  from 
any  cause;  long  head;  tumor  of  occiput; 
spastic  rigidity  of  neck  muscles — all  of 
which  produce  extension;  and  congenital 
goitre,  coils  of  cord  under  the  chin;  obesity 
and  dropsical  condition;  muscular  hypo- 
tonus  of  the  asphyxiated  and  dead  child — 
all  of  which  prevent  flexion.  (4)  Causes 
residing  in  the  parturient  canal:  narrow 
pelvis,  especially  short  transverse  diameter; 
rigid  os;  the  projecting  rim  of  a  placenta 
prsevia ;  prominent  ischial  spine ;  distended 
maternal  bladder. 

Ahlfeld  regards  all  causes  resident  in 
the  uterus  or  fetus  as  primary,  and  all 
causes  which  obtain  in  the  birth  passages 
as  secondary.  In  Winckel's  cases,  30 
per  cent,  had  hydramnios;  22  per  cent, 
had  coiling  of  the  cord  about  the  child;  30 
per  cent,  had  contracted  pelves,  etc.  The 
most  frequent  association  in  these  cases, 
in  Winckel's  experience,  is  contracted  pel- 
vis, large  child,  and  pendulous  abdomen. 

Position  and  Relative  Frequency  (Fig. 
662). 

i.  Left   mento-anterior,  mento   lasva 

anterior,   L.    M.   A.    (Fig.  663), 

second  in  frequency. 

II.  Right  mento-anterior,  mento  dex- 

tra  anterior,  R.  M.  A.  (Fig.  667). 

III.  Right  mento-posterior,  mento  dex- 
tra  posterior,  R^^M.  P.  (Fig. 
671),  most  frequent. 

IV.  Left  mento-posterior,  mento  laeva 
posterior,  L.  M.  P.  (Fig.  675). 

The  relative  frequency  of  the  several 
positions  is,  first,  right  mento-posterior; 
and,  second,  left  mento-anterior.  Right 
mento-anterior  and  left  mento-posterior 
are  very  rarely  seen.  (Compare  Presenta- 
tion, page  423,  and  Fig.  662.) 

Mechanism. — I.  Left  Mento-ante- 
rior, L.  M.  A.  (Fig.  663).— The  part 
played  by  the  occiput  in  vertex  presen- 
tation is  simulated  by  the  chin  in  face 
presentation.  Face  presentation,  how- 
ever, differs   somewhat  in  the  mechanism 


FETAL  DYSTOCIA   FROM  FAULTY   ATTITUDE. 


511 


of  labor  from  vertex,  although  the  same 
general  principles  obtain.  The  forces  act 
at  a  disadvantage  in  face  presentation, 
(i)  The  direction  of  uterine  contraction 
is  not  in  direct  line  with  the  lowest  por- 
tion of  the  presenting  part  as  in  vertex 
presentation  (Fig.  684).  (2)  The  cervical 
vertebras,  owing  to  extension  of  the  head, 
are  bent  almost  at  right  angles,  hence  the 
head  is  dragged  rather  than  pushed  through 
the  pelvis,  with  a  resulting  tremendous 
friction,  loss  of  power,  prolonged  labor, 
and  dangerous  compression  of  the  vessels 
of  the  neck.  (3)  Again,  in  the  internal 
rotation  of  the  face  another  difficulty  in 
the  ordinary  mechanism  of  labor  presents 
itself.  Anterior  rotation  of  the  chin  does 
not  occur  so  readily  as  anterior  rotation  of 
the  vertex  because  the  distance  from  the 
trunk  to  the  chin  is  less  than  from  the 
trunk  to  the  occiput.  The  depth  of  the 
sides  of  the  pelvis  is  3I  inches  (8.75  cm.) 
and  the  distance  from  the  trunk  to  the 
chin  in  face  presentations  is  about  2  inches 
(5  cm.),  hence,  either  the  neck  must  be 
elongated  in  order  to  allow  the  chin  to 
reach  the  resistance  of  the  pelvic  floor  or 
the  shoulders  and  thorax  must  enter  the 
pelvis  with  the  face.  The  second  is  im- 
possible without  causing  impaction,  and 
the  first  results  in  prolonged  labor  and 
danger  to  the  fetus,  hence  interference  is 
often  called  for  in  face  presentations  at 
the  time  of  rotation  of  the  chin  anteriorly. 
Further,  when  the  chin  finally  reaches  the 
pelvic  floor,  the  irregular,  soft,  often  oede- 
matous  chin  is  not  acted  upon  so  positively 
by  the  factors  which  produce  anterior  rota- 
tion as  is  the  regular,  hard  vertex,  and 
hence  the  tardy  rotation  of  the  face  and 
greater  necessity  for  instrumental  inter- 
ference in  this  stage  of  the  mechanism  of 
labor  in  face  presentation,  (i)  Extension 
and  moulding  of  the  head:  The  head  passes 
through  several  stages  of  inclination  before 
complete  extension  is  reached,  and  the 
occiput  lies  close  to  the  dorsum.  During 
this  process  moulding  takes  place  to  a 
certain  extent,  though  it  is  difficult  of 
accomplishment  and  requires  a  long  time. 
This  is  due  to  the  mature  ossification  of 
the  bones  and  sutures  of  the  face.     The 


SECOND  FACE  POSITION. 
Right  Mento-anterior,  R.  m.  a 


/> 


Fig.  667. — Face  at  Pelvic  Inlet. 


Fig.  668. — Chin  and  Right  Cheek  in 
THE  Cervix. —  (From  author's  draw- 
ing.) 


Fig.  669. — Face  at  the  Pelvic  Floor 
.    Before  Anterior  Rotation  of  the 
Chin. 


Fig.  670. — Delivery  op  the  Face 
AFTER  Anterior  Rotation  of  the 
Chin. — (Autlior's  photograph.) 


512 


PATHOLOGICAL   LABOR. 


THIRD  FACE  POSITION. 

Right  mento-Posterior,  R.  M.  P. 


V     ^'"<^  / 


Fig.  671. — Face  at  Pelvic  Inlet. 


Fig.  672. — Chin  and  Right  Cheek  in 
THE  Cervix. —  {From  author's  draw- 
ing.) 


^ 


Fig.  673. — Face  at  the  Pelvic  Floor 
before  Anterior  Chin  Rotation. 


Fig.  674. — Delivery  of  the  Head 
AFTER  Anterior  Rotation  of  the 
Chin. — {Author's  photograph.) 


shape  of  the  head  after  an  ordinary  face 
delivery  is  that  of  a  flattened  arch,  while 
the  frontal  bones  are  increased  in  their 
convexity  and  the  supra-occipital  is  pressed 
back.  (Figs,  680  and  681.)  The  diameter 
of  the  face  occupying  the  right  oblique 
diameter  of  the  inlet  is  the  cervico-breg- 
matic,  and  this  is  so  long  (3!  inches — 9.5 
cm.)  that  it  necessitates  quite  extensive 
moulding  of  the  head,  especially  if  the 
adaptation  is  inclined  to  be  close.  The 
entire  back  of  the  head  must  be  bent 
downward  and  pressed  against  the  neck. 
(Fig.  680.)  The  anterior  or  left  cheek  is 
on  a  lower  level  than  the  posterior  (Fig. 
664).  In  face  presentations  the  cheek 
which  comes  first,  or  the  anterior  one,  is 
the  seat  of  the  caput,  and  the  size  of  the 
latter  will  be  in  accordance  with  the  amount 
of  time  which  elapses  before  anterior  rota- 
tion of  the  chin  occurs.  Delay  after  rota- 
tion involves  the  entire  face  in  the  forma- 
tion of  a  caput.  If  there  is  no  unusual 
delay  in  extension,  the  lower  part  of  the 
face  is  exposed,  while  in  case  of  delay  the 
caput  is  formed  at  the  upper  portion  of 
the  face.  (2)  Engagement  and  descent  of 
the  face  (Fig.  665):  The  chin  is  the  main 
point  of  the  mechanism,  and  it  is  so  far 
ahead  of  the  cervico-bregmatic  diameter 
that  it  is  deep  in  the  pelvis  by  the  time 
this  diameter  has  passed  the  pelvic  inlet. 
Here  sometimes  occurs  a  temporary  stand- 
still for  a  time,  for  if  the  region  of  the 
sagittal  suture  remains  in  the  sacro-iliac 
notch,  the  sacral  promontory  will  prevent 
the  head  from  turning  backward,  while  all 
this  time  the  lower  part  of  the  anterior 
sulcus  is  imparting  continually  a  forward 
impetus  to  the  chin.  The  contractions  of 
the  uterus  as  well  as  extension  of  the  neck 
of  the  fetus  bring  the  fetal  face  to  the  floor 
of  the  pelvis.  The  extension  of  the  fetal 
neck  sometimes  amounts  to  2  inches  (5 
cm.)  before  the  chin  and  the  pelvic  floor 
are  brought  into  contact.  (3)  Anterior 
rotation  of  the  chin  (Fig.  665):  In  order 
that  anterior  rotation  of  the  chin  may 
take  place,  the  force  of  propulsion  must 
be  strong  enough  to  press  the  chin 
down  to  the  lowest  point  possible  in 
the  pelvis.     After  the  occiput  passes  the 


FETAL  DYSTOCIA   FROM   FAULTY   ATTITUDE. 


513 


sacral  promontory  the  chin  rotates  ante- 
riorly under  the  symphysis  pubis,  while 
the  bregma  sinks  into  the  hollow  of 
the  sacrum.  (4)  Flexion  and  expulsion 
of  the  head  (Figs.  666,  670,  674,  678):  In- 
ternal rotation  being  partially  or  entirely 
complete,  the  force  of  uterine  contrac- 
tion causes  the  expulsion  of  the  head  by 
flexion;  the  chin,  mouth,  nose,  eyes,  and 
forehead  appearing  successively  in  the 
vulva.  (5)  Rotation  of  the  trnnk  and 
restitution  of  the  head:  Following  the 
same  law  as  in  vertex  presentation  (page 
447),  the  lower  or  left  shoulder  or  ante- 
rior shoulder  rotates  to  the  symphysis, 
causing  the  child's  face  to  turn  to  the 
mother's  left  thigh  (restitution)  (Fig.  678). 
(6)  Expulsion  of  the  trunk:  This  is  the 
same  as  in  vertex  presentation  (page  447, 
Fig.  675). 

II.  Right  Mento-anterior  Position, 
R.  M.  A.  (Fig.  667). — Here  the  same  general 
principles  obtain  as  regards  (i)  extension 
and  moulding  of  the  head  and  (2)  engage- 
ment and  descent,  these  being  the  same  as 
in  the  left-mento  anterior  (Fig.  667).  (3) 
Rotation  of  the  chin  is  from  right  to  left 
(Fig.  669).  (4)  Flexion  and  expulsion  of 
the  head  are  the  same  as  in  the  L.  M.  A. 
(Fig.  670).  (5)  In  rotation  of  the  trunk 
and  restitution  of  the  head  the  right  ante- 
rior or  lower  shoulder  rotates  anteriorly 
to  the  symphysis,  and  the  consequent  res- 
titution of  the  child's  face  is  toward  the 
right  thigh  of  the  mother  (Fig.  674).  (6) 
Expulsion  of  the  body  follows. 

III.  Right  Mentq-posterior  Posi- 
tion, R.  M.  P.  (Fig.  671). —  Extension 
and  moulding  of  the  head  and  (2)  engage- 
ment and  descent  are  the  same  as  in  the 
anterior  positions,  except  that  they  are 
apt  to  be  tardy,  as  in  posterior  vertex 
positions  (page  459,  Fig.  673).  (3)  Ante- 
rior rotation  of  the  chin  from  right  to  left 
about  the  right  half  of  the  pelvis  to 
the  symphysis  is  the  normal  mechanism. 
Should  anterior  rotation  fail,  we  have  re- 
sulting a  persistent  mento- posterior  posi- 
tion (Fig.  756).  (Compare  page  551.)  (4) 
Flexion  and  expulsion  of  the  head  are  the 
same  as  in  the  anterior  pesitions  (Fig.  674). 
(S)  In  rotation  of  the  trunk  and  restitu- 

33 


FOURTH  FACE  POSITION. 
Left  Mento-Posterior,  L.  m.  p 


'T 


Fig.    675. — Face    at    Pelvic    Inlet. 


Fig.  676. — -Chin  and    Left   Cheek    in 
THE  Cervix. 


Fig.  677. — Face  at  the  Pelvic  Floor 
before  Anterior  Chin  Rotation. 


Fig.  67S. — Restitution  of  the  Head 
after  Anterior  Rotation  of  the 
Chin  and  Expulsion. 


514 


PATHOLOGICAL  LABOR. 


MOULDING  IN  FACE  PRESENTATION. 


\ 


Fig.  679. — Before  Moulding. 


Fig.    680. — After  Moulding. —  (Author's  case.) 


Fig.  681. — Fetal  Skull  showing  Moulding  in 
Face  Presentation. — (Author's  collection.) 


tion  of  the  head  the  right  anterior 
or  lower  shoulder  rotates  to  the 
symphysis.  (6)  Expulsion  of  the 
body  follows. 

IV.  Left  Mento-posterior 
Position,  L.  M.  P.  (Fig.  675). — 
The  cervico-bregmatic  diameter  en- 
ters the  pelvis  in  the  left  oblique 
diameter,  the  chin  pointing  to  the 
left  sacro-iliac  synchondrosis,  (i) 
Extension  and  moulding  of  the 
head  and  (2)  engagement  and  de- 
scent occur  as  in  the  R.  M.  P.  posi- 
tion (Fig.  677).  (3)  Anterior  rota- 
tion of  the  chin  from  left  to  right 
about  the  left  half  of  the  pelvis 
to  the  symphysis  is  the  normal 
mechanism.  Should  anterior  rota- 
tion fail,  we  have  resulting  a  per- 
sistent mento-posterior  position 
(comparepagessi)  (Fig.  756).  (4) 
Flexion  and  expulsion  of  the  head 
are  the  same  as  in  anterior  posi- 
tions (Fig.  674).  (5)  In  rotation 
of  the  trunk  and  restitution  of  the 
head  the  left  anterior  or  lower 
shoulder  rotates  to  the  symphysis 
(Fig.  675).  (6)  Expulsion  of  the 
body  follows. 

Diagnosis. — The  recognition  of 
facial  positions  by  external  ex- 
amination has  been  pronounced 
impracticable  by  many  diagnos- 
ticians. Ahlfeld,  however,  states 
that  this  type  of  faulty  attitude 
may  be  recognized  occasionally, 
while,  according  to  Schatz,  great 
pains  and  experience  make  such 
recognition  practicable  in  routine 
diagnosis.  Facial  positions  may 
be  made  out  by  external  manipu- 
lation alone,  before  dilatation  of 
the  cervix,  as  follows:  Pressure 
above  the  pelvic  inlet  reveals  the 
presence  of  a  prominent  head 
(occiput).  Having  located  the 
occiput  in  this  manner,  the  small 
parts  and  fetal  heart-sounds  should 
be  recognized  on  the  opposite  side 
of  the  uterus.  The  method  re- 
commended by  Schatz  depends  for 
success  upon  mapping  out  the  con- 


FETAL   DYSTOCIA    FROM   FAULTY   ATTITUDE. 


515 


vexity  of  the  abdominal  aspect  of  the  fetus,  and  upon  the  demonstration  that 
this  convexity  could  not  represent  the  normal  dorsal  arch  of  the  vertex  presen- 
tation (Fig.  684)  and  is  as  follows:  If  the  fetus  is  in  the  cephalic  position  with 
breech  in  the  fundus,  the  spinal  convexity  will  be  made  more  pronounced  in  a  ver- 


ts*, 


J' 


Fig.  682. — Face  Presentation.     Originally  in  the  right  mento-posterior  position, 
thor's  case   at  the   Emergency   Hospital. — {From  a  photograph.) 


Au- 


tex  presentation,  by  pressing  upon  the  breech  in  the  direction  of  the  pelvic  inlet, 
and  the  other  hand  will  be  able  to  trace  the  curvature  from  the  breech  down- 
ward. But  in  a  facial  presentation  a  convexity  is  also  present,  and  an  abdominal 
curvature  which  may  simulate  the  dorsal  arch.  In  palpating  this  convexity  from 
the  breech  downward,  the  hand  would  locate  the  legs  at  the  outset.     Again,  if  the 


516 


PATHOLOGICAL   LABOR. 


height  of  the  convexity  really  represents  the  child's  chest,  pressure  made^by  the 
hand  upon  the  breech  may  be  transmitted  to  the  hand  upon  the  chest.  In  facial 
presentation,  in  comparison  with  the  normal  vertex  presentation,  the  fetus  appears 
to  have  a  short  back,  and  limbs  may  be  felt  on  both  sides  of  the  uterus,  the 
legs  above  and  at  one  side,  the  arms  below  and  upon  the  other  side.  This 
peculiarity  makes  it  expedient  to  exclude  the  probability  of  a  twin  pregnancy 


'^ 


Fig.  683. — Face  Presentation.     Originally  in  the  right  mento-posterior  position, 
thor's  case  at  the  Emergency  Hospital. — {From  a  photograph.) 


Au- 


before  making  a  diagnosis  of  a  face  presentation.  In  regard  to  internal  recog- 
nition of  face  presentation,  the  usual  method  consists  in  mapping  out  the  facial 
line,  from  the  root  of  the  nose  to  the  chin. 

Prognosis. — In  primiparous  labors  the  prognosis  for  mother  and  child  is 
considerably  more  unfavorable  than  in  vertex  cases.  The  prolongation  of  labor 
is  an  element  which  is  naturally  unfavorable  to  mother  and  child  alike.      The 


FETAL  DYSTOCIA  FROM  FAULTY  ATTITUDE. 


517 


mother's  condition  is  also  prejudiced  by  her  great  efforts  to  expel  the  child, 
while  the  special  danger  to  the  latter  is  found  in  the  hyperextension  of  the  head. 
The  danger  of  birth  trauma,  with  or  without  subsequent  infection,  is  present  here 
as  in  all  labor  in  abnormal  positions.  In  multi- 
parous  labors  the  prognosis  for  mother  and 
child  is  said  to  be  but  little  if  at  all  worse 
than  in  vertex  presentations.  The  great  im- 
provement in  this  respect  in  comparison  with 
the  fatality  of  the  remote  past  is  to  be  ascribed 
to  the  recognition  of  the  fact  that  face  presen- 
tation can  take  care  of  itself  and  that  patience 
and  expectancy  are  valuable  traits  in  the  ob- 
stetrician, if  the  labor  is  too  far  advanced  to 
permit  of  correction  of  the  faulty  position.  In 
2 1  face  cases  occurring  in  the  Moscow  Mater- 
nity Hospital  during  a  period  of  ten  years,*  17 
terminated  without  assistance,  2  by  forceps, 
and  2  by  craniotomy.  All  the  mothers  recov- 
ered. An  element  in  the  prognosis  is  found  in 
the  position  of  the  chin,  since,  a  much  higher 
mortality  is  found  in  posterior  positions.  In 
the  latter  the  mother  is  exposed  to  the  danger 
of  severe  laceration  of  the  perineum,  while  the 
child  has  a  relatively  small  prospect  of  sur- 
vival. The  maternal  mortality  has  been 
placed  at  6  percent.;  the  fetal  at  15  percent. 
The  dangers  for  the  mother  are  (i)  those  of 

protracted  labor,  or  (2)  of  deformed  pelvis,  which  latter  so  often  complicates  a 
face  presentation.  The  dangers  to  the  child  are  (i)  those  of  prolonged  labor; 
(2)  cerebral  congestion  and  apoplexy;  (3)  asphyxia  from  pressure  on  the  vessels 
of  the  neck;  (4)  injury  to  the  eyes  during  vaginal  examination. 


Fig.  684. — Direction  of  Forces 
IN  THE  Conversion  of  a  Face 
Presentation  into  a  Vertex. — 
(Ahlfeld.) 


Position  of  Fetus. 


Left   mento-ante- 
rior.     L.  M.  A. 


Left  mento-ante- 
rior.     R.  M.  A. 


Right  mento-pos- 
terior.  R.  M.  P. 


Chin  to  left  acetabulum,  forehead  to  right 
sacro-iliac  joint;  back  to  right;  extremities 
to  left. 


Chin  to  right  acetabulum,  forehead  to  left 
sacro-iliac  joint;  back  to  left;  extremities 
to  right. 


Left     mento-pos- 
terior.  L.  M.  P. 


Chin  to  right  sacro-iliac  joint,  forehead  to  left 
acetabulum;  back  to  left;  extremities  to 
right. 


Chin  to  left  sacro-iliac  joint,  forehead  to  right 
acetabulum;  back  to  right;  extremities  to 
left. 


Fetal  Heart-sounds. 


Left    side  of  abdomen, 
below  umbilicus. 


Right  side  of  abdomen, 
below  umbilicus. 


Right  side  of  abdomen, 
below  umbilicus. 


Left   side   of  abdomen, 
below  umbilicus. 


Treatment. — In  this  presentation  more  than  in  any  other,  successful  treat- 
ment depends  upon  a  thorough  acquaintance  with  the  mechanism  of  labor. 
The  membranes  should  be  preserved  as  long  as  possible,  since  the  face  is  a 
poor  dilator  and  the  fore-water  protects  it  from  injury.     The  friends  should 

*Solowieff:   "  Centralbl.  f.  Gynak.,"  Leipzig,  1S9S,  No.  30. 


518 


PATHOLOGICAL  LABOR. 


PRESENTATION    OF     THE    ANTE 
RIOR   PARIETAL    BONE   OR 
EAR;    NAEGELE'S  OB- 
LIQUITY. 


be  informed  that  the  face,  when  born,  will  be  very  much  distorted.  One  should 
recollect  that  in  a  very  large  proportion  of  cases  a  face  presentation  does  not 
require  intervention  until  the  face  reaches  the  pelvic  floor,  and  this  holds  good 
in  both  anterior  and  posterior  positions  of  the  chin.  Fortunately,  moreover, 
a  persistent  posterior  position  of  the  chin  is  of  rare  occurrence,  not  more  than 

in  one  per  cent,  of  all  face  positions,  and 
in  spite  of  the  fact  that  the  right  mento- 
posterior position  is  first  in  frequency. 
In  the  absence  of  other  factors  of  maternal 
or  fetal  dystocia  expectancy  is  the  key-note 
in  the  treatment. 

1.  At  the  Pelvic  Inlet. — In  both  anterior 
and  posterior  positions  the  case  should  be 
allowed  to  proceed  without  intervention,  so 
long  as  labor  progresses  satisfactorily.  The 
membranes  must  be  preserved,  however, 
and  complete  extension  secured  by  upward 
pressure  on  the  forehead.  Failure  of  en- 
gagement of  the  face  at  the  inlet  calls  for 
conversion  into  a  vertex,  followed  by  high 
forceps  or  spontaneous  labor  in  posterior 
chin  positions,  and  podalic  version  and  ex- 
traction in  anterior  chin  positions,  or  con- 
version and  high  forceps  in  both. 

2.  In  the  Pelvic  Cavity. — Delay  in  an- 
terior rotation  of  the  chin  often  occurs  for 
physical  reasons,  hence  it  must  be  favored 
by  securing  complete  extension,  by  drawing 
forward  the  chin,  by  pushing  back  the  fore- 
head; or  by  putting  the  fingers  or  a  blade 

y  JQIV*      'Xlk^W.  °^  ^^^  forceps  under  and  behind  the  chin, 

>^^>Jl^^^^l^fi^^^         *°  ^^^^  *^^  latter  some  hard  substance  to 

"y^V^A    ^^^^^ /JMt   ■]        act  upon.     (See  Operations,  Part  X.)     For 

the  treatment  of  persistent  mento-posterior 
cases  see  page  552. 

Fig.  686.-AT  the  Pelvic  Inlet.  y.     PRESENTATION     OF     THE     ANTE- 

RIOR PARIETAL  BONE  OR  EAR. 
NAEGELE'S  OBLIQUITY.  rPig 
685.) 

Normally  the  anterior  parietal  bone  in 
vertex  and  bregma  presentations  is  lowest 
and  most  prominent  in  the  cervix  and  va- 
gina. When,  however,  excessive  lateral 
flexion  of  the  head  occurs,  to  the  extent, 
perhaps,  of  the  presentation  of  the  anterior 
ear,  Naegele's  obliquity  of  the  head  is  said  to  be  present.  Naturally  the  sagittal 
suture  approaches  the  sacral  promontory  and  the  posterior  parietal  bone  is  carried 
upward  and  backward.  The  latter  is  often  found  flattened  after  delivery  and 
even  depressed  or  fractured,  and  is  overlapped  by  the  anterior.  An  exaggerated 
bregma  presentation  is  usually  present.     The  etiology  of  this  complication  is  to 


Fig.  685. — At  the  Pelvic  Inlet. 


Fig.  6S7. — Anterior    Parietal 
AND  Ear  in  the  Cervix. 


FETAL   DYSTOCIA   FROM   FAULTY  ATTITUDE. 


519 


PRESENTATION    OF    THE    POSTE- 
RIOR PARIETAL  BONE  OR  EAR. 
LITZMANN'S  OBLIQUITY. 


be  found  in  a  pendulous  abdomen,  flattened  or  generally  contracted  pelvis,  or 
other  obstruction  permitting  of  the  lateral  flexion  of  the  fetal  head.  The  diag- 
nosis is  not  difficult  by  ordinary  vaginal  palpation ;  but  should  doubt  exist,  the 
introduction  of  the  whole  hand  into  the  vagina  will  remove  any  uncertainty.  In 
left  positions  of  the  vertex  the  right  parietal 
bone  and  perhaps  the  right  ear  will  be  found 
presenting;  the  small  fontanelle  high  and 
to  the  left  and  the  greater  toward  the  right. 
Should  the  obstruction  not  be  too  great,  the 
head  may  reach  the  pelvic  floor  in  this  way. 
The  prognosis  depends  entirely  upon  the 
cause  of  the  condition.  In  the  lesser  forms 
of  pelvic  contraction  the  prognosis  is  favor- 
able, also  when  the  anomaly  occurs  as  a 
transient  condition,  which  it  does  in  about 
one-third  of  all  cases.  The  treatment  con- 
sists in  relief  of  the  pendulous  abdomen 
or  anteverted  uterus  with  an  abdominal 
support  or  bandage  in  pregnancy  (Fig. 
228),  and  the  manual  correction  of  the 
condition  in  labor  if  necessary.  Nearly  one- 
half  of  the  cases  rectify  themselves  spon- 
taneously. Of  course,  special  treatment  of 
the  case  is  often  demanded. 


PRESENTATION  OF  THE  POSTE- 
RIOR PARIETAL  BONE  OR  EAR. 
LITZMANN'S     OBLIQUITY.       (Fig. 

) 


Fig.  688. — At  the  Pelvic  Inlet. 


^J^^^^if 


qr~" 


Fig.  689. — At  the  Pelvic  Inlet. 


Here  the  sagittal  suture  approaches  the 
symphysis,  with  the  resulting  presentation 
of  the  posterior  parietal  bone  or  ear.  In- 
complete flexion  with  the  sinciput  lower 
than  the  occiput  will  often  be  present.  The 
condition  usually  occurs  in  markedly  flat- 
tened pelves,  the  latter  obstruction  result- 
ing in  a  lateral  flexion  of  the  fetal  body  and 
head,  the  reverse  of  the  Naegele  obliquity. 
Only  rarely  does  Litzmann's  obliquity  oc- 
cur in  normal  pelves.  The  highest  degree 
of  this,  as  of  Naegele 's  obliquity,  is  the  pre- 
sentation of  an  ear.  The  diagnosis  may 
cause  some  uncertainty  unless  the  whole 
hand  is  introduced  into  the  vagina,  when 
the  conditions  above  described  will  be 
readily   recognized.       The   prognosis   will 

usually  depend  on  the  amount  and  variety  of  the  pelvic  contraction;  it  is  favor- 
able in  the  so-called  spontaneous  cases  and  in  moderate  degrees  of  contraction. 
It  is  unfavorable  in  a  moderate  degree  of  general  contraction  should  the  brow 
enter  the  pelvis.  The  treatment  in  spontaneous  cases  consists  in  manual  correc- 
tion; and  in  pelvic  contraction,  in  appropriate  treatment  of  the  obstruction. 


Fig.   690. — Posterior  Parietal  Bone 
AND  Ear  in  the  Cervix. 


520 


PATHOLOGICAL   LABOR. 


VII.    PROLAPSE    OF   THE    ARMS.      DORSAL    DISPLACEMENT    OF   THE 

ARM. 

In  an  obstetric  sense  prolapse  of  the  arms  is  important  only  in  connection 
with  cephalic  presentations, — vertex,  brow,  face, — as  prolapse  of  the  upper  ex- 
tremities in  breech  and  shoulder  presentations  has  little  if  any  effect  upon  the 
course  of  labor,  and  is  rather  favorable  than  otherwise.  Presentation  of  a  hand 
frequently  occurs  before  rupture  of  the  membranes,  and  after  rupture  either  dis- 
appears by  recession  or  the  presentation  is  con- 
verted into  a  prolapse;  the  arm  then  usually 
occupies  the  hollow  of  the  sacrum  and  is  often 
combined  with  prolapse  of  the  cord.  If  the  arm 
is  far  in  advance,  there  is  a  chance  of  the  head 
being  deflected  into  the  iliac  fossa  while  the 
shoulder  descends  and  a  shoulder  presentation 
occurs.  If,  however,  the  hand  can  just  be  pal- 
pated by  the  side  of  the  head,  it  is  likely  that 
the  latter  will  be  bom  first  while  the  hand 
stays  behind.  Also  the  hand  when  at  the  side 
of  the  pelvis — namely,  at  one  end  of  the  trans- 
verse diameter — is  not  so  apt  to  be  an  impedi- 
ment as  when  it  lies  in  front,  for  in  this  latter 
position  it  encroaches  on  the  conjugate  diam- 
eter. The  position  of  the  prolapsed  hand  is 
generally  at  one  end  of  the  bitemporal  diam- 
eter. Sometimes  rotation  is  interfered  with. 
If,  however,  the  hand  lies  against  the  occiput, 
it  may  prevent  its  descent  at  least  for  a  time, 
and  cause  head  extension  at  the  pelvic  inlet 
(Figs.  693,  695,  and  696). 

Etiology. — The  causes  are  found  in  any- 
thing that  disturbs  the  natural  relationship  of 
the  presenting  part  with  the  pelvic  inlet.  Thus 
malpresentations,  such  as  shoulder,  brow,  or 
face,  are  causes,  since  they  do  not  properly 
engage  at  the  inlet;  or  anomalies  in  the  shape 
of  the  uterus  which  have  developed  during 
pregnancy  from  some  cause  or  are  due  to 
tumor,  hydramnios,  or  twins;  or  displacement 
due  to  a  pendulous  abdomen.  Pelvic  contrac- 
tion, as  in  the  prolapse  of  the  cord,  is  a  com- 
mon cause,  as  it  prevents  a  proper  adjustment 
of  the  presenting  part  to  the  inlet.  For  the 
same  reason  multiple  presentation,  as  in  twins, 
Rupture  of  the  membranes  in  the  sitting  or 
standing  posture,  especially  in  multiparae,  and  sudden  exertion  on  the  part  of 
the  mother  during  or  even  after  engagement  of  the  presenting  part,  must  be 
recognized  as  etiological  factors.  Death  of  the  fetus  with  loss  of  its  muscular 
tonicity  must  also  be  included. 

Diagnosis. — This  is  a  simple  matter,  and  the  possibility  of  this  accident 
should  always  be  one  of  the  mental  queries  at  all  first  and  subsequent  internal 
examinations  of  labor. 


OF 


Fig.    691. — Lateral   Obliquity 
THE  Head  in  Vertex  Presenta 

TION. 


and  a  premature  fetus  are  causes. 


FETAL  DYSTOCIA   FROM   FAULTY  ATTITUDE.  521 

Prognosis. — In  shoulder  and  breech  presentations  prolapse  of  one  or  both 
arms  is  rather  a  favorable  condition,  and  affects  the  prognosis  accordingly. 
For  this  reason  I  am  never  accustomed  to  replace  the  prolapsed  arm  or  arms 
under  such  circumstances.  The  advantage  lies  in  the  fact  that  we  can  usually 
apply  a  sling  or  soft  fillet  to  the  arm  or  arms,  keep  them  prolapsed,  and  thus  the 
subsequent  danger  of  the  arm  or  arms  becoming  extended  and  causing  impaction 
of  the  after-coming  head  is  obviated.  Prolapse  of  an  arm  in  vertex  presentation 
is  often  a  serious  condition.  The  arm  occupying  the  inlet  with  the  vertex  may 
result  in  a  lateral  deviation  of  the  head,  and  a  vertex  presentation  may  thus  be 
converted  into  a  bregma,  brow,  or  face,  or,  if  the  head  is  freely  movable,  even 
into  a  shoulder.  Or,  a  less  serious  condition,  an  arm  prolapsed  behind  the  sym- 
physis may  cause  lateral  flexion  and  presentation  of  the  anterior  parietal  bone 
(Naegele's  obliquity)  or  of  the  posterior  (Litzmann's  obliquity).  The  cause  of 
the  prolapse — whether  it  originates  in  the  bony  pelvis,  the  maternal  soft  parts, 
or  the  fetus — must  not  be  lost  sight  of  as  affecting  the  prognosis. 

Treatment. — (i)  In  shoulder  and  breech  presentations  no  treatment,  in  my 
opinion,  is  required,  other  than  to  secure  the  prolapsed  arm  or  arms  with  a  sling 
in  order  to  prevent  subsequent  extension  alongside  or  above  the  after-coming 
head.  (2)  In  instances  of  prolapse  of  an  arm  or  arms  with  the  head  when  the 
latter  is  well  engaged,  an  expectant  treatment  should  be  followed;  and  if  delayed 
labor  occurs,  endangering  fetus  or  mother,  the  forceps  should  be  applied  to  the 
head,  care  being  taken  not  to  include  the  prolapsed  arm,  and  the  fetus  extracted 
as  in  medium  or  low  forceps  operations.  It  will  facilitate  extraction  if  moderate 
traction  is  also  made  with  a  sling  to  the  prolapsed  arm.  Impaction  in  the  case 
of  a  dead  fetus  of  course  demands  perforation.  (3)  Manual  reposition  of  the 
arm  may  be  preceded,  as  a  matter  of  duty,  by  an  attempt  at  postural  reposi- 
tion— namely,  placing  the  patient  in  the  exaggerated  semi-prone,  knee-chest 
or  Trendelenburg  posture.  Postural  reposition  alone  rarely  succeeds.  (4) 
When  the  head  is  movable  at  the  inlet  or  is  extra-medial  b3v  reason  of  the  pro- 
lapsed arm  filling  in  one  side  of  the  pelvis,  and  the  arm  thus  constitutes  an 
actual  obstruction,  manual  reposition  should  be  performed.  This  is  the  same 
as  in  the  case  of  a  prolapsed  leg,  (See  page  522.)  (5)  Version  and  extraction 
may  be  required  if  reposition  fails  and  indications  of  delayed  labor  demand 
intervention. 

Dorsal  Displacement  of  the  Arm  (Figs.  692,  694). — In  cephalic  and  breech 
presentations  it  occasionally  happens  that  an  arm  is  not  only  prolapsed,  but  is  so 
displaced  that  the  forearm  lies  transversely  across  the  back  of  the  neck  behind 
the  occiput  and  forms  a  ridge  or  elevation  in  the  generally  uniform  fetal  ellipse 
which  may  catch  upon  the  pelvic  inlet  or  a  rigid  cervix  and  constitute  a  serious 
obstruction  to  labor.  Diagnosis  :  The  condition  is  the  more  dangerous  because, 
as  no  appreciable  change  occurs  in  the  presentation,  it  naturally  escapes  diagnosis 
unless  the  hand  of  the  attendant  is  passed  above  the  head  to  explore  for  the  cause 
of  delay.  Such  an  exploration  under  ether  is  always  called  for  when  forceps- 
indication  with  no  marked  disproportion  between  the  head  and  fetus  is  evident 
and  traction  fails  to  bring  down  the  head.  Treatment :  (i)  In  Cephalic  Presen- 
tation.— In  spite  of  the  obstruction  the  fetus  can  sometimes  (a)  be  delivered  by 
moderate  traction  with  the  forceps.  Strong  traction  must  not  be  employed  for 
fear  of  injury  to  the  fetal  neck.  (6)  The  forceps  failing,  an  attempt  should  be 
made  with  the  hand  passed  between  the  shoulder  and  the  pelvic  wall  to  flex  the 
forearm  back  into  its  proper  place  over  the  scapula,  and  the  lateral  and  anterior 
thoracic  walls.  Fracture  of  the  arm  is  occasionally  unavoidable,  (c)  The  forceps 
and  manual  rectification  having  failed,  combined  or  internal  podalic  version  under 


522  PATHOLOGICAL  LABOR. 

proper  conditions  of  fetus  and  uterus  must  be  performed.  (2)  In  Breech  Pres- 
entation AND  Breech  Extraction. — Delay  here  from  dorsal  displacement  of 
the  arm  is  more  important  than  in  cephalic  presentation,  since  shorter  time  is 
allowed  for  removing  the  obstruction  and  fetal  asphyxia  in  the  mean  time  is  liable 
to  occur,  (a)  A  conservative  as  well  as  effective  plan  of  procedure  is  to  bring 
down  the  non-displaced  arm,  to  put  a  sling  upon  it,  and,  by  using  this  arm  as  a 
tractor  as  well  as  by  grasping  the  trunk,  to  rotate  the  latter  in  the  direction  that 
will  disengage  the  displaced  arm.  (b)  The  replacement  thus  accomplished  will 
usually  be  only  partial,  and  it  will  be  necessary,  after  rotating  the  displaced 
arm  into  the  posterior  part  of  the  pelvis,  to  pass  the  whole  or  half  hand  into  the 
pelvis  and  sweep  the  now  partially  displaced  arm  over  the  face  and  chest.  It 
may  possibly  be  necessary  deliberately  to  fracture  the  arm  in  order  to  liberate  the 
fetus  in  time  to  prevent  its  death  by  asphyxia.     (Compare  Part  X.) 


Vlll.  PROLAPSE  OF  THE  LEGS. 

Prolapse  of  the  lower  extremities  is  unusual  in  any  presentation.  It  is  rather 
favorable  than  otherwise  in  breech  and  shoulder  presentations,  and  occurs,  as  a 
rule,  only  when  the  fetus  is  dead,  immature,  or  macerated.  In  certain  breech 
presentations  there  is  extension  of  one  or  both  thighs  from  vigorous  movements 
on  the  part  of  the  fetus  or  from  sudden  outflow  of  liquor  amnii.  Thus  one  or 
both  feet  or  one  or  both  knees  or  a  knee  and  a  foot  present.  An  influencing 
factor  in  this  condition  is  the  fact  that  the  breech  does  not  fully  occupy  the 
lower  uterine  segment,  especially  when  there  is  much  liquor  amnii.  Frequency : 
Footling  presentations  are  said  to  occur  once  in  92  cases,  or  in  a  little  over  i  per 
cent,  of  all  breech  cases.  Knee  presentations  are  very  rare,  occurring  once  in 
3000  cases.  The  simultaneous  presentation  of  hand  and  foot  is  extremely  rare. 
Treatment:  (i)  In  shoulder  and  breech  presentations  no  treatment  is  required 
other  than  to  secure  the  prolapsed  leg  with  a  sling.  In  the  rare  instances  in 
which  prolapse  of  the  leg  occurs  with  cephalic  presentation  (vertex,  brow,  or 
face)  the  treatment  will  vary  according  to  circumstances  (Figs.  696,  697). 
(See  Part  X.^ 


IX.    PROLAPSE  OF  THE  UMBILICAL  CORD. 

Synonyms:  Prolapsus  Funis;  Chorda  Prae via;  Funicular  Presentation. 

Definition. — In  this  condition  a  loop  of  the  umbilical  cord  descends  into  the 
pelvis  in  advance  of  the  presenting  part.  If  the  membranes  remain  unruptured, 
the  condition  is  known  as  presentation  of  the  cord,  but  after  rupture,  when  the 
cord  descends  into  the  vagina,  it  is  called  prolapse  of  the  cord.  Before  rupture, 
the  loop  of  cord  may  be  felt  through  the  membranes  moving  in  the  liquor  amnii, 
and  from  the  very  beginning  of  labor  it  presents  at  the  pelvic  inlet.  It  may  be 
carried  down  by  the  sudden  outflow  of  liquor  amnii  when  the  membranes  rupture, 
or  the  loop  may  be  forced  down  by  muscular  action  by  the  side  of  the  engaged 
head,  and  thus  escape  from  the  vulva.  Sometimes  both  arms  of  the  loop  are 
seen  side  by  side;  in  other  cases  the  two  parts  are  separated  by  a  fetal  part. 
The  most  common  position  in  which  the  loop  is  found  is  in  front  of  one  of  the 
sacro-iliac  joints  or  of  the  cotyloid  cavity.  It  is  seldom  directly  in  front  of  the 
sacrum  or  behind  the  pubic  arch.  The  last-named  positions  are  most  dangerous, 
as  they  give  most  chance  for  compression  of  the  cord  by  the  fetal  parts  (Figs. 
700  and  701). 

Frequency. — The  frequency  of  this  complication  varies,  in  different  countries 


<^        CO 


.,-'-'-"T;^:r?^s>^^ 


523 


524 


PATHOLOGICAL  LABOR. 


and  in  different  institutions,  with  the  frequency  of  pelvic  deformity  and  the 
posture  of  the  parturient  woman  during  labor.  On  the  whole,  it  is  not  very  infre- 
quent. One  estimate  gives  it  as  occurring  once  in  from  200  to  300  cases  of  labor, 
but  the  limits  according  to  various  authors,  range  between  one  in  65  and  one  in 
500  cases.  In  2200  confinements  in  New  York  city  I  found  the  cord  was  pro- 
lapsed in  26  cases,  or  in  1.18  per  cent.,  or  once  in  84.6  cases. 

Etiology. — The  cause  of  this  condition  is  found  in  a  lack  of  accommodation 
between  the  presenting  part  and  the  lower  uterine  segment  and  the  pelvic  inlet. 
Malpresentations,  malpositions,  deformities  of  the  head,  and  contractions  of  the 
pelvis  act  as  predisposing  causes.  In  26  cases  of  prolapse  of  the  cord  I  found  14 
vertex  presentations,  i  brow,  3  shoulder,  and  8  breech,  one  of  the  last  being  a 
prolapsed  foot  as  well.  In  9  of  the  26  cases  some  form  of  pelvic  contraction  was 
present.  Eight  of  the  cases  were  in  primiparae  and  18  in  multiparse.  Excessive 
right  lateral  obliquity  of  the  uterus,  uterine  fibromata  or  myomata,  hydramnios, 

too  long  cord,  marginal  insertion  of  the 
cord,  placenta  praevia,  plural  pregnancy, 
multiparity,  pendulous  abdomen,  a  male 
fetus,  complex  presentation,  or  the  pres- 
ence of  a  very  small  fetus  in  premature 
labor,  predispose  to  prolapse  of  the  cord. 
Cases  have  been  reported  in  which  this 
complication  has  occurred  in  successive 
pregnancies,  and  in  the  absence  of  an  ob- 
vious cause,  predisposition  has  been  said  to 
be  the  etiological  factor.  The  upright  posi- 
tion on  the  part  of  the  mother  at  the  time 
of  rupture  of  the  membranes,  and  a  sudden 
escape  of  the  liquor  amnii,  may  act  as  excit- 
ing causes,  as  may  also  violent  movements, 
or  efforts  at  bearing-down,  particularly  if 
ergot  has  been  used  prematurely  in  the  last 
instance. 

Diagnosis. — The  diagnosis  differs  some- 
what whether  made  before  or  after  the 
rupture  of  the  membranes.  It  should 
be  simple  enough  after  the  rupture  of  the 
membranes,  especially  if  the  loop  of  cord 
has  fallen  into  the  vagina  or  outside  the 
vulva.  It  may  be  distinguished  from  a  prolapsed  intestine  by  the  absence  of 
a  mesentery,  and  by  the  characteristic  twists  of  the  umbilical  cord  which  can  be 
felt,  and,  if  the  child  still  lives,  by  the  presence  of  pulsation  in  the  cord.  In 
some  cases,  however,  pulsation  in  the  cord  ceases  a  short  time  before  the  death 
of  the  child,  so  that  the  heart  should  be  auscultated  before  death  is  decided  to 
have  occurred.  If  the  membranes  are  still  unruptured  and  the  pulsation  is  ab- 
sent, the  diagnosis  is  not  quite  so  clear.  Pulsations  which  occur  in  the  vaginal 
or  uterine  arteries  may  be  distinguished  from  those  of  the  cord  by  being  syn- 
chronous with  the  pulse  of  the  mother.  Before  the  escape  of  the  liquor  amnii, 
the  cord,  being  non-resisting,  is  pushed  ahead  of  the  examining  finger  until  it  is 
really  beyond  palpation.  Prolapsed  cord  has  also  to  be  differentiated  from  the 
presence  of  a  foot  or  a  hand  in  the  vagina,  an  ectopia  of  the  fetal  intestines,  and 
an  oedematous  and  lacerated  lip  of  the  cervix. 

Prognosis. — The  mortality  among  children  in  this  condition  amounts  to  50 


Fig. 


700. — Prolapse  of  the  Cord  in 
Vertex  Presentation. 


FETAL   DYSTOCIA    FROM   FAULTY  ATTITUDE. 


525 


per  cent.  The  prognosis  for  the  child  depends  on  the  time  of  labor  at  which  the 
prolapse  occurs,  the  presentation  and  position  of  the  fetus,  the  condition  of  the 
membranes,  the  condition  of  the  cervix,  the  amount  of  cord  prolapsed,  and  the 
gravity  of  the  abnormality  causing  the  accident.  The  great  danger  for  the  child 
is  from  asphyxia  due  to  compression  of  the  cord.  Head  presentation  carries  the 
greatest  danger  with  it.  The  danger  is  less  in  proportion  to  the  greater  length  of 
time  that  the  membranes  remain  intact,  and,  after  their  rupture,  in  proportion  to 
the  rapidity  of  delivery.  The  amount  of  the  cord  prolapsed  and  the  region  of  the 
pelvis  into  which  it  descends  also  influence  the  prognosis.  The  fetal  mortality 
is  higher  in  primiparae  and  in  oversize  of  the  fetus. 

The  prognosis  for  the  mother  depends  upon  the  gravity  of  the  abnormality 
which  causes  the  accident,  and  of  the  operation  demanded.  Mental  disturbance 
and  breast  complications  subsequent  to  the  death  of  the  fetus  may  have  some 
effect  on  the  mother.  Cases  do  occur  in  which,  from  various  causes,  the  cord  is 
tightly  stretched,  and  is  thus  so  shortened  that  the  placenta  is  prematurely  de- 
tached, with  resulting  hemorrhage.  In  my 
26  collected  cases,  one  mother  died  on  the 
fifth  day,  undoubtedly  as  the  result  of  the 
operation  to  save  the  child,  and  5  of  the 
26  children  were  still-bom. 

Treatment. — The  treatment  of  this 
condition  is  most  important  because  of 
the  high  mortality  among  children. 
Whatever  measures  are  instituted  should 
be  promptly  applied. 

1.  Preventive   Treatment   consists 
in  posture  of  the  parturient,  preservation 
of  the  membranes,  and  immediate  correc- 
tion of  lateral  displacement  of  the  present- 
ing part.     Many  cases  are  due  to  improper 
management  of  labor.     The  membranes 
should   never   be  ruptured   prematurely 
without    a   positive   indication,   and  the 
waters  should  never  be  allowed  to  gush 
from  the  uterus  when  the  woman  is  in 
the  erect  or  sitting  posture.     With  an  ex- 
cess of  the  liquor  amnii,  a  gradual  escape  of  the  waters  should  be  aimed  at  by 
partially  occluding  the  vaginal  outlet  with  gauze  or  cotton.     In  conditions  favor- 
ing prolapse  the  woman  should   be  kept  in  the  dorsal  posture  during  the  first 
as  well  as  the  second  stage. 

2.  Curative  Treatment. — If  the  child  is  dead,  the  presentation  or  prolapse 
of  the  cord  does  not,  of  course,  constitute  a  special  indication,  for  the  interests 
of  the  mother  do  not  require  that  the  fetus  shall  be  extracted  at  once. 

In  the  curative  treatment  of  presentation  of  the  funis  before  dilatation  of  the 
cervix  has  taken  place,  or  rupture  of  the  membranes,  active  interference  is  not  in- 
dicated. Every  effort  should  be  made  to  prevent  the  premature  rupture  of  the 
membranes.  For  this  purpose  a  Barnes  bag  may  be  introduced,  or  the  vagina  may 
be  tamponed.  The  patient  should  be  cautioned  against  straining,  and  should 
assume  the  exaggerated  latero-prone  position  (Part  X)  on  the  side  opposite  to  that 
on  which  the  cord  lies,  in  order  that  gravity  may  favor  the  return  of  the  displaced 
cord.  The  knee-chest  position  is  also  frequently  useful  in  causing  the  return  of 
the  cord.     If  the  fetal  heart-sounds  begin  to  fail,  the  cord  should  be  pushed  up  be- 


FiG.  701. — Prolapse  of  the  Cord  in  a 
Doubled  Fetus,  the  Anterior  Fetal 
Plane  Presenting. 


526  PATHOLOGICAL   LABOR. 

tween  the  pains,  care  being  taken  not  to  rupture  the  membranes.  This  should  be 
done  while  the  patient  is  in  the  knee-chest  position.  If  the  cord  does  not  return, 
the  membranes  should  be  ruptured,  and  sufficient  descent  of  the  head  secured  to 
retain  the  cord,  by  expression  of  the  fetus  or  by  using  forceps.  After  the  cord 
has  been  replaced,  the  patient  should  lie  upon  the  side,  as  above  described,  and 
with  the  hips  elevated  by  a  pillow.  If  the  accoucheur  possesses  the  requisite 
experience  and  skill,  and  if  the  mother's  condition  permits,  he  may  perform 
version  by  thq  combined  method,  but  without  bringing  down  the  foot  into  the 
vagina.     The  foot  should  be  secured  by  a  fillet. 

In  the  treatment  of  presentation  of  the  funis  after  dilatation  of  the  cervix,  if 
the  head  remains  above  the  brim  and  cannot  be  made  to  engage,  there  are 
two  alternatives:  manual  or  instrumental  reposition  and  version.  Too  much 
handling  of  the  cord,  however,  is  dangerous  to  the  fetus.  If  reasonable  efforts 
at  reposition  fail,  version  should  be  performed,  unless  it  is  so  dangerous  to  the 
mother  as  to  be  considered  unjustifiable. 

Manual  reposition  is  best  done  while  the  patient  is  in  the  exaggerated  latero- 
prone  or  knee-chest  position.  While  counter-pressure  is  made  over  the  fundus, 
the  hand  should  be  passed  into  the  cervix,  the  head  pushed  a  little  to  one  side, 
and  the  cord  carried  up  beyond  the  head,  and,  if  possible,  to  a  position  behind  the 
neck.  During  this  manipulation  the  cord  should  be  balanced  on  the  tips  of  as 
many  fingers  as  possible  and  not  grasped  in  the  hollow  of  the  hand.  This  act 
of  reposition  should  be  done  as  rapidly  as  possible.  Manipulations  should  be 
suspended  during  uterine  contractions.  The  hand  should  be  gradually  with- 
drawn, and  the  descent  of  the  head  into  the  cervical  canal  aided  by  pressure 
over  the  fundus,  or  the  application  of  the  forceps.  After  reposition  the 
woman  should  be  placed  on  the  side  opposite  to  that  at  which  the  prolapse 
developed. 

Instrumental  reposition  will  become  necessary  if  rupture  of  the  membranes 
takes  place  before  dilatation  of  the  cervix,  since  the  time  occupied  in  securing 
dilatation  would  very  likely  prove  fatal  to  the  child.  The  best  repositor  is  an 
ordinary  English  catheter  (See  Part  X).  The  stylet  is  made  to  pass  out  from  the 
eye  of  the  catheter,  a  loop  of  disinfected  bobbin  is  passed  loosely  around  the 
cord,  and  is  attached  to  the  stylet,  which  is  then  withdrawn  into  the  catheter 
and  pushed  to  the  tip,  in  order  to  hold  the  tape  in  position.  The  catheter  and 
cord  are  then  carried  up  as  far  as  possible,  the  stylet  is  withdrawn  to  avoid 
possible  compression,  and  the  catheter  is  left  in  position.  Every  effort  should 
then  be  made  to  induce  engagement  as  described  above.  If  efforts  at  reposition 
are  not  promptly  successful,  manual  dilatation,  followed  by  version  or  forceps, 
according  to  the  indications,  should  be  performed.  Another  method  of  slinging 
the  cord  is  shown  in  Part  X. 

In  face  presentations  version  should  be  performed,  unless  there  are  contra- 
indications, since  the  face  does  not  completely  fill  the  cervical  canal,  and  the 
replaced  loop  is  likely  to  re-prolapse.  In  prolapse  of  the  foot  in  breech  pres- 
entations the  cord  is  not  in  danger  until  the  breech  enters  the  cervix.  In 
breech  presentations  pressure  upon  the  cord  may  be  relieved  by  bringing  down 
a  foot,  but  if  the  fetal  heart-sounds  begin  to  fail,  extraction  should  be  as  rapid 
as  is  consistent  with  the  safety  of  the  mother.  In  shoulder  presentations  no 
modification  of  the  usual  management  is  indicated.  In  the  very  rare  cases  in 
which  the  head  is  impacted,  or  has  passed  the  inlet,  and  the  cord  pulsates,  the 
use  of  the  forceps  is  indicated.  After  the  child  is  dead  the  condition  does  not 
call  for  interference.  If  there  are  still  other  complications,  such  as  placenta 
praevia  or  shoulder  presentation,  the  same  treatment  is  indicated  as  at  first 


FETAL  DYSTOCIA   FROM   FAULTY  PRESENTATION.  527 

described.  When  prolapsed  cord  offers  the  only  complication,  it  should  be 
restored  as  quickly  as  possible.  Throughout  the  management  of  the  case  the 
operator  or  an  assistant  should  listen  at  intervals  for  the  fetal  heart.  If 
asphyxia  appears  to  be  impending  before  dilatation  of  the  cervix  is  com- 
plete, the  Braxton-Hicks  method  of  version  may  be  performed,  although  the 
foot  should  not  be  brought  below  the  level  of  the  os,  where  it  may  be  held 
by  a  sling  until  dilatation  is  complete.  If  fetal  asphyxia  is  impending  after 
dilatation  is  complete,  podalic  version  should  be  performed  if  the  head  is 
movable  at  the  inlet;  otherwise  forceps  must  be  applied.  In  my  series  of  26 
cases,  above  quoted,  with  a  fetal  mortality  of  19.2  per  cent.,  8  children  were 
delivered  by  forceps,  9  by  version,  4  by  manual  extraction  in  breech  cases,  and 
5  spontaneously.     Records  are  wanting  in  2  cases. 


FETAL  DYSTOCIA  FROM  FAULTY  PRESENTATION. 

X.  PELVIC  PRESENTATION. 

Definition. — Pelvic  or  breech  presentation  represents  positions  of  the  fetus 
in  which  the  inferior  pole  of  the  fetal  ellipse  is  found  at  the  pelvic  inlet,  in  the 
vagina,  or  at  the  vulva.  It  is  classed  as  a  longitudinal  presentation,  and  therefore 
is  amenable  to  the  conditions  of  that  class.  The  positions  are  named  in  accord- 
ance with  the  location  of  the  fetal  sacrum  (page  529),  It  is  unnecessarily  com- 
plicating to  describe  in  this  connection  a  foot  and  knee  presentation.  Prolapse 
of  the  feet  and  legs  is  merely  a  complication  of  a  pelvic  presentation  as  prolapse 
of  the  cord  and  hands  is  in  other  presentations — vertex,  bregma,  brow,  face, 
or  shoulders.  It  is  useful,  however,  to  distinguish  between  a  simple  pelvic  pres- 
entation and  a  mixed  one.  In  a  simple  breech  presentation  the  lower  extrem- 
ities are  flexed  on  the  anterior  surface  of  the  body.  Flexion  is  limited  to  the 
hip-joint,  the  knee  being  in  extension.  The  breech  alone  presents  at  the  inlet. 
(Figs.  703,  704).  In  a  mixed  breech  presentation  the  lower  extremities  maintain 
the  physiological  attitude  throughout,  hips,  knees,  and  ankles  alike  exhibiting 
some  degree  of  flexion ;  so  that  the  feet  are  found  in  some  relationship  with  the 
breech  at  the  pelvic  inlet — perhaps  above,  perhaps  below  (Fig.  707). 

Frequency. — Statistics  covering  a  vast  number  of  child-births  show  that  about 
one  labor  in  thirty-two  is  a  breech  presentation,  the  percentage  being  3.2.  A 
large  proportion  of  breech  cases  is  found  in  premature  deliveries,  multiple  preg- 
nancies, and  anomalous  labors  (page  423).  Simple  breech  occurs  in  about  60  per 
cent,  of  cases.  In  2200  labors  I  found  pelvic  presentation  occurred  in  82  cases 
or  3.72  per  cent.,  or  once  in  26  labors. 

Etiology. — The  etiology  of  breech  cases  is  complex,  so  that  the  theoretical 
causal  factors  cannot  always  be  brought  into  relationship  with  this  anomalous 
presentation.  In  general  it  may  be  stated  that  anything  which  interferes  with 
the  normal  shape  of  the  fetal  ellipse  or  changes  the  shape  of  the  ovoid  uterine 
cavity  after  the  thirty-second  week  may  result  in  a  malpresentation,  such  as 
pelvic ;  in  other  words,  there  is  failure  of  one  or  more  factors  governing  the  deter- 
mination of  vertex  presentation  (compare  page  424).  Certain  conditions  predis- 
pose to  breech  presentations:  (i)  First,  the  causes  of  faulty  attitude  in  general, 
including  pelvic,  shoulder,  and  possibly  face  presentation.  These  include,  on  the 
part  of  the  mother,  relaxation  of  the  uterine  and  abdominal  walls,  abnormal 
mobility  of  the  uterus  (conditions  found  in  women  who  have  borne  many  chil- 


528 


PATHOLOGICAL   LABOR. 


dren);  distention  of  the  uterus  (hydramnios),  deformity  of  the  uterus,  whether 
due  to  malformation  (uterus  arcuatus,  bicomis,  etc.)  or  to  fibroids;  contracted 

pelvis;  placenta  praevia.  (2) 
On  the  part  of  the  fetus  the 
corresponding  factors  are  pre- 
maturity (we  must  expect 
breech  presentation  in  every 
second  case  of  labor  before 
the  eighth  month,  page  423); 
multiple  pregnancy;  mon- 
strosities; fetal  diseases,  dead 
and  macerated  fetuses.  We 
frequently  see  the  coincidence 
of  several  of  these  factors  in  a 
given  case. 

Positions  and  Relative  Fre- 
quency.— 

I.  Left  sacro- anterior, 
Sacro  laeva  anter- 
ior, L.  S.  A.  (Fig. 
706),  most  fre- 
quent. 
II.  Right  sacro-anterior, 
Sacro  dextra  an- 
terior,   R.    S.    A. 

,...  (Fig.  715)- 

/        ^'  III.  Right      sacro-poster- 

\  /        '  ior,  Sacro  dextra 

posterior,  R.  S.  P. 

-Mixed  Breech  Presentation.     Compare  ^^^S-  7I9).  second 

Fig.  707,  in  frequency. 


^^ 


Fig. 


702. 


Fig.  703. — Simple  Breech  Presen- 
tation. 


^.. 


Fig.   704. — Simple  Breech  Presentation. 


FETAL   DYSTOCIA   FROM   FAULTY  PRESENTATION. 


529 


IV.  Left  sacro-posterior,  Sacro  lasva  posterior,  L.  S.  P.  (Fig.  723). 

The  left  sacro-anterior  is  the  most  frequent,  and  the  right  sacro-posterior  the 
next.  In  163  pelvic  presentations,  Naegele  found  120  left  sacro-anterior  and  40 
right  sacro-posterior.  The  same  factors  determine  the  relative  frequency  of  the 
several  breech  positions  as  those  of  the  vertex  (page  426).  To  understand  this 
one  must  keep  in  mind  the  shape  of  the  fetal  ellipse;  the  shape  of  the  uterine 
cavity;  the  torsion  of  the  uterus  upon  its  long  axis,  and  the  fact  that  in  pelvic 
as  in  vertex  presentation  the  longest  horizontal  diameter  of  the  fetal  ellipse  is 
an  antero-posterior  and  not  a  transverse  diameter  (Figs.  702,  704).  This  is 
brought  about  by  the  flexion  of  the  thighs,  legs,  arms,  and  head  upon  the 
anterior  fetal  plane  in  the  normal  attitude  or  posture  (page  420). 

Mechanism. — I.  Left  Sacro-anterior,  L.  S.  A.  (Fig.  706). — The  same  stages 
obtain  here  as  in  the  mechanism  of  vertex  presentation.  The  bitrochanteric 
diameter  (Fig.  707)  approaches  the  pelvic  inlet  in  the  latter's  left  oblique  diam- 
eter, the  fetal  back  looking  to  the  left  and  front  (Fig.  706).  (i)  Moulding 
of  the  breech:  Increased  intra- 
uterine pressure  results,  in  ad- 
dition to  moulding,  in  more 
perfect  flexion  of  the  limbs 
and  head.  No  movement  an- 
alogous to  flexion  in  vertex  or 
extension  in  face  presentation 
occurs,  nor  does  a  typical 
tumor  like  the  caput  succed- 
aneum  form.  This  process  is 
also  one  of  adaptation  The 
breech  is  swollen  either  from 
simple  oedema  or  the  condi- 
tion may  be  more  severe  and 
present  a  much  enlarged,  dark 
surf ac e.  Itismorec ommonly 
seen  over  the  anterior  hip, 
though  it  may  reach  the  geni- 
tal regions,  especially  the  scro- 
tum in  males.  If  the  knees  or 
feet  present,  they  may  become 
oedematous.     (2)  Engagement 

and  descent:  By  reason  of  the  irregular  shape  of  the  breech  this  stage  is  often 
prolonged.  The  left  anterior  or  lower  hip  first  enters  the  inlet  and  cervix  (Figs. 
707  and  708)  and  slowly  the  uterus  forces  the  breech  onward  into  the  pelvic  cavity 
until  the  left  hip  meets  with  the  resistance  of  the  pelvic  floor.  (3)  Anterior  rota- 
tion of  the  left  hip:  Rotation  of  the  buttocks  occurs  when  the  pelvic  floor  is  reached. 
It  must  be  clearly  understood  that  while  the  greatest  horizontal  diameter  of  the 
fetal  ellipse  is  the  antero-posterior,  yet  the  greatest  diameter  of  the  presenting 
part  or  breech  is  the  transverse  diameter,  the  bitrochanteric,  3^  inches  (8.75  cm.) 
(Fig.  704).  One  must  also  remember  that  in  the  stage  of  descent  that  buttock  or 
trochanter  which  lies  in  the  anterior  segment  of  the  pelvis  is  the  lowest,  and  hence 
the  first  to  be  influenced  by  the  trough-like  shape  of  the  pelvic  floor  and  deflected 
to  the  front  at  the  pelvic  outlet,  thus  bringing  the  long  diameter  of  the  presenting 
part  .(jDitrochanteric)  into  the  long  diameter  of  the  pelvic  outlet  (antero-posterior), 
and  fulfilling  the  great  principle  in  the  mechanism  of  labor,  namely,  accommoda- 
tion (Figs.  708,  709).  The  left,  lower,  or  anterior  buttock  is  thus  brought  to  the 
34 


Fig. 


93-99  J^ 


705. — Relative    Frequency    of    the    Breech 
Positions, 


530 


PATHOLOGICAL   LABOR. 


FIRST  BREECH  POSITION. 
Left  Sacro-Anterior,  L.  S.  a. 


Fig.  706. — Breech  at  the  Pelvic 

Inlet. 


Fig.  707. — Breech  at  the  Pelvic 

Inlet. 


Fig.     708. — Left    Buttock    in    the 
Cervix. 


Fig.     709. — Left    Buttock,    in    the 
Vulva. — (From  a  photograph.) 


symphysis  pubis  by  the  rotation  of  the 
breech  in  its  entirety.  (4)  Expulsion  of  the 
breech  and  lateral  flexion  of  the  body:  When 
the  anterior  hip  has  reached  the  pubis,  and 
the  posterior  the  posterior  portion  of  the 
pelvic  floor,  the  impetus  given  the  fetus  by 
the  posterior  segment  bends  forward  the 
breech  in  its  entirety  and  a  lateral  curva- 
ture of  the  trunk  occurs  (Fig.  138).  The 
lateral  curvature  soon  becomes  decided  and 
the  buttock  may  be  seen  at  the  vulval  open- 
ing. The  trunk  is  propelled  into  the  pelvic 
cavity  and  the  anterior  hip  becomes  fixed 
beneath  the  pubic  arch.  Next  the  posterior 
hip  makes  onward  progress  until  the  poste- 
rior buttock  appears  overthe  fourchette,  fol- 
lowed by  the  trochanter.  With  the  birth  of 
the  posterior  part  of  the  breech  the  peri- 
neum withdraws  from  the  pelvis  of  the 
fetus,  and  on  account  of  the  posterior  sur- 
face of  the  breech  being  relieved  entirely  of 
pressure  there  is  decreased  curvature  and 
the  fetal  trunk  straightens  out,  freeing  the 
anterior  hip  from  its  forced  position  against 
the  arch  of  the  pubis  (Fig.  718).  Expulsion 
of  the  trunk  now  readily  follows.  The 
thighs  are  always  flexed  when  no  prolapse 
occurs  and  the  legs  are  often  extended  (Fig. 
703).  Extension  of  the  legs  I  do  not  con- 
sider an  abnormal  condition,  as  it  is  due  to 
the  tight  birth  canal  "peeling"  them  up,  so 
to  speak,  along  the  fetal  body.  Normally 
the  arms  preserve  their  original  position 
upon  the  chest  of  the  fetus  and  are  thus  ex- 
pelled. An  unfortunate  complication  arises 
should  one  or  both  arms  become  extended 
along  the  sides  of  the  head  within  the  pelvis. 
The  hips,  the  legs,  and  the  trunk  appear  in 
quick  succession,  and  the  child  is  delivered 
up  to  its  waist.  Almost  simultaneously  the 
shoulders  enter  the  inlet  and  the  umbilicus 
appears  at  the  vulva.  The  bisacromial  di- 
ameter of  the  shoulder  engages  in  the  left 
oblique  diameter  of  the  pelvic  inlet  and  the 
shoulders  descend  until  the  left,  lower,  or 
anterior  shoulder  reaches  the  pelvic  floor. 
The  left  shoulder  then  rotates  anteriorly 
from  right  to  left,  causing  the  bisacromial 
diameter  to  correspond  to  the  antero-pos- 
terior  diameter  of  the  pelvic  outlet.  The 
anterior  shoulder  becomes  fixed  under  the 
pubic  arch.     The  arms,  flexed  on  the  chest. 


FETAL  DYSTOCIA   FROM   FAULTY  PRESENTATION. 


531 


and  the  shoulders,  first  the  right  or 
posterior,  and  later  the  left  or  ante- 
rior, are  delivered.  (5)  Rotation  of  the 
head  and  restitution  of  the  trunk:  The 
head,  regarded  as  a  lever,  is  pressed 
upon  at  its  longer  arm  by  the  uterus, 
and  this  serves  to  keep  it  flexed  or  to 
increase  existing  flexion.  The  head 
engages  and  descends.  The  occipito- 
frontal diameter  of  the  head  enters  the 
pelvis  in  its  right  oblique  diameter.  In 
perfect  flexion  of  the  head  and  normal 
posture  of  the  child  the  vertex  or  occi- 
put is  the  only  prominent  or  project- 
ing portion.  Consequently  at  the  pel- 
vic floor  it  is  this  pole  of  the  head 
which  alone  meets  with  any  resistance 
and,  following  the  usual  law,  is  de- 
flected anteriorly,  bringing  the  long 
diameter  of  the  head  into  that  of  the 
outlet.  Anterior  rotation  of  the  occi- 
put we  know  clinically  rarely  fails,  and 
then  because  of  an  extended  head  or 
some  anomaly  either  in  the  shape  of 
the  head  or  in  the  parturient  tract. 
Coincident  with  head  rotation,  slight 
restitution  of  the  trunk,  bringing  the 
fetal  dorsum  to  the  front,  is  sometimes 
observed.  (6)  Expulsion  of  the  head: 
Although  acting  at  a  disadvantage  by 
reason  of  the  relatively  small  size  of 
the  head,  the  uterus  by  contracting 
acts  upon  the  vault  of  the  cranium. 
The  occiput  still  being  the  projecting 
and  prominent  portion  of  the  head. 


Fig.  710. — Delivery  of  the 
Head  with  the  Occiput 


After-coming 
Anterior. 


Fig.  711. — Delivery  of  the 
Head   with  the  Occiput 


After-coming 
Anterior. 


Fig.  712. — Delivery  of  the  After-coming 
Head  with  the  Occiput  Anterior. 


Fig.  713. — Delivery  of  the  After-com- 
ing Head  with  the  Occiput  Poste- 
rior.    First  Method. 


Fig.  714. — Delivery  of  the  After-com- 
ing Head  with  the  Occiput  Posterior. 
Second  Method. 


532 


PATHOLOGICAL   LABOR. 


SECOND  BREECH  POSITION. 
RIGHT  SACRO-ANTERIOR,  R.  S.  A. 


Fig.   715. — Breech  at    Pelvic  Inlet. 


Fig.   716. — Breech  at   Pelvic  Inlet 


•/ 


Fig.     717. — Right    Buttock 
Cervix. 


Fig.     718. — Breech    in    the    Vulva. 
Expulsion   of   both    Buttocks. 


and  in  the  anterior  segment  of  the  pelvic 
outlet,  is  naturally  caught  and  held  by  the 
bony  fork  of  the  pubic  arch,  leaving  the  long 
or  sinciput  extremity  of  the  cephalic  lever 
to  be  influenced  by  the  contraction  of  the 
uterus  and  pelvic  floor  and  to  be  driven 
down  into  the  vulval  opening,  causing  the 
head  to  be  bom  by  a  movement  of  flexion; 
the  chin,  mouth,  nose,  eyes,  forehead,  an- 
terior fontanelle,  and  lastly  the  occiput 
passing  over  the  perineum  in  the  order 
named  (Figs.  710,  711,  712). 

Posterior  Rotation  of  the  Occiput. — In 
rare  cases,  not  more  than  2  per  cent.,  ante- 
rior rotation  of  the  occiput  fails,  the  sinciput 
end  of  the  cephalic  lever  rotates  to  the  pu- 
bic arch  and  the  occiput  to  the  coccyx. 
This  complication  results  from  incomplete 
flexion  of  the  head,  whereby  the  sinciput  of 
the  after-coming  head  becomes  as  promi- 
nent as  the  occiput  or  more  so,  and  hence  is 
equally  or  to  a  great  extent  influenced  by 
the  greater  resistance  of  the  posterior  part 
of  the  pelvic  floor,  and  is  rotated  anteriorly. 
Two  terminations  of  a  persistent  occipito- 
posterior  position  of  the  after-coming  head 
are  possible:  (i)  Uterine  contractions  force 
the  sinciput,  or  long  end  of  the  head  lever, 
under  the  pubic  arch  and  flex  the  head 
through  the  vulval  orifice;  the  chin,  mouth, 
nose,  eyes,  forehead,  and  occiput  appearing 
in  the  order  named  under  the  pubis  (Fig. 
714).  (2)  Occasionally  extension  of  the 
head  takes  place  at  the  pelvic  inlet  and  the 
occipito-mental  diameter  (5^  inches — 13.97 
cm.)  is  brought  in  coincidence  with  the  an- 
tero-posterior  diameter  of  the  inlet,  thus 
presenting  a  mechanical  impossibility.  In 
these  cases  contraction  of  the  uterus  forces 
the  chin  over  and  upon  the  upper  portion  of 
the  symphysis  and  thus  fixes  the  face  end  of 
the  cephalic  lever.  The  occipital  or  short 
end  of  the  head  lever  alone  being  free,  is 
forced  by  uterine  contraction  down  to  the 
pelvic  floor  and  the  head  is  bom  through 
the  vulval  orifice  by  a  movement  of  con- . 
tinued  extension;  the  occipital  protuber- 
ance, the  small  and  large  fontanelles,  fore- 
head, nose,  mouth,  and  lastly  the  chin  being 
bom  in  the  order  named  (Fig.  713). 

II.  Right  Sacro-anterior   Position, 
R.  S.  A.   (Fig.    7x5). — The   bitrochanteric 


FETAL   DYSTOCIA    FROM   FAULTY   PRESENTATION. 


633 


diameter  approaches  the  pelvic  inlet  in  the 
latter's  right  oblique  diameter,  the  fetal 
back  looking  to  the  right  and  front,  (i) 
Moulding  of  the  breech:  Same  as  in  Position 
I  (page  529).  (2)  Engagement  and  descent. 
Same  as  in  Position  I  (page  529).  (3)  An- 
terior rotation  of  the  right  hip:  This  occurs  for 
the  same  reason  as  in  Position  I  (page  530), 

(4)  Expulsion  of  the  breech  and  lateral  flexion 
of  the  body:  Compare  Position  I  (page  530). 

(5)  Rotation  of  the  head  and  restitution  of  the 
trunk:  The  occipito-frontal  diameter  enters 
the  left  oblique  pelvic  diameter  and  the 
occiput  rotates  to  the  pubis  from  right  to 
left  (Fig.  715).  Restitution  occurs  as  in 
Position  I.  (6)  Expulsion  of  the  head  (Fig. 
710):  See  Position  I  (page  531). 

III.  Right  Sacro-posterior  Position, 
R.  S.  P.  (Fig.  719). — The  bitrochanteric 
fetal  diameter  approaches  the  left  oblique 
pelvic  diameter;  the  fetal  back  looks  to  the 
right  and  rear  (Fig.  720).  (i)  Moulding  of 
the  breech  and  (2)  Engagement  and  descent 
occur  as  in  Positions  I  and  II.  (3)  Anterior 
rotation  of  the  right  hip  now  occurs  (Fig. 
721).  (4)  Expulsion  of  the  breech  and  lateral 
flexion  of  the  body  follow  (see  pages  582  and 
531)  (Fig.  722).  (5)  Rotation  of  the  head  and 
restitution  of  the  trunk:  The  occipito-frontal 
fetal  diameter  enters  the  right  oblique  pel- 
vic diameter,  the  occiput  pointing  to  the 
right  sacro-iliac  synchondrosis.  Rotation 
of  the  occiput  follows  from  this  latter  point 
around  the  right  pelvic  wall  and  to  the  sym- 
physis, for  reasons  already  stated,  in  all  but 
less  than  2  per  cent,  of  cases  (Fig.  719).  (6) 
Expulsion  of  the  head  now  occurs  as  in  Posi- 
tions I  and  II  (Fig.  710). 

IV.  Left  Sacro-posterior  Position, 
L.  P.  S.  (Fig.  723). — The  bitroch^.nteric 
fetal  diameter  approaches  the  left"  (Oblique 
pelvic  inlet  diameter;  the  fetal  back  looks 
to  the  left  and  rear  (Fig.  724).  (i)  Moulding 
of  the  breech  and  (2)  Engagement  and  descent 
occur  as  in  Positions  I  and  II  (Fig.  725). 
(3)  Anterior  rotation  of  the  left  hip:  This  oc- 
curs from  left  to  right  to  the  median  line 
(Fig.  725).  (4)  Expulsion  of  the  breech  and 
lateral  flexion  of  the  body:  As  in  I,  II,  and 
III  (Fig.  710).  (5)  Rotation  of  the  head  and 
restitution  of  the  trunk:  The  occipito-frontal 
fetal  diameter  enters  the  left  oblique  pelvic 


THIRD  BREECH  POSITION. 
RIGHT  SACRO-POSTERIOR,  R.  S.  P. 


Fig.   719. — Breech  at   Pelvic  Inlet. 


Fig.    720.— Breech  at  Pelvic  Inlet. 


C 


Fig.     721. — Right    Buttock    in     thb 
Cervix. 


Fig.    722. — In    the    Vulva.      Escape 
OF  THE  Anterior  or  Right  Leg. 


534 


PATHOLOGICAL  LABOR. 


.1 


FOURTH  BREECH  POSITION. 
LEFT  SACRO-POSTERIOR,  L.  S.  P. 


diameter,  the  occiput  pointing  to  the  left  sacro-iliac  synchondrosis.  Rotation 
of  the  occiput  around  the  left  side  of  the  pelvis  to  the  symphysis  occurs  at  the 
floor  of  the  pelvis  (Fig.  723).     (6)  Expulsion  of  the  head  follows  (Fig.  710). 

Prognosis. — For  the  mother:  The  prognosis  in  respect  to  the  mother's  survival 
corresponds  with  that  of  occipital  presentations  in  all  cases  which  terminate 
spontaneously,  although  intervention  is  required  much  more  frequently  in  breech 
cases.  The  likelihood  of  perineal  rupture  is  also  greater.  For  the  child:  The  prog- 
nosis for  the  fetus  is  much  more  unfavorable  than  in  occipital  presentations ;  the 
average  mortality  being  20  per  cent.  The  chief  danger  is  from  asphyxia,  which 
often  occurs  as  the  after-coming  head  passes  the  pelvic  inlet  coincident  with  the 
birth  of  the  navel.  An  additional  peril  is  compression  of  the  cord  between  the 
fetal  parts  and  the  pelvic  bones.  Complete  compression  for  five  to  ten  minutes  is 
sufficient  to  kill  a  strong,  healthy  child.  Third,  premature  detachment  of  the  pla- 
centa may  cause  death  of  the  child.  Par- 
tial detachment  often  results  irrespective  of 
the  fetal  position  when  the  uterus  is  par- 
tially emptied;  but  while  this  has  no  special 
significance  in  head  presentations,  it  is 
otherwise  when  the  head  is  still  in  the  uterus 
and  respiration  impossible.  Under  these 
circumstances  the  prognosis  is  not  neces- 
sarily ominous  because  it  may  be  improved 
by  treatment.  In  regard  to  the  prognosis 
of  particular  types  of  pelvic  presentations, 
the  best  outlook  occurs  in  mixed  breech 
cases,  because  the  entire  circumference  of 
the  trunk  and  lower  extremities  serves  to 
dilate  the  birth  tract.  Conversely,  if  the 
feet  constitute  the  presenting  part,  the 
prognosis  is  unfavorable  because  a  complete 
foot  presentation  cannot  dilate  the  birth 
tract  sufficiently  for  delivery  of  the  after- 


FiG.  723. — Breech    at  Pelvic  Inlet. 


Fig.  724. 


jREECH  AT   Pelvic  Inlet. 


Fig.   725. — Left  Buttock  in  Cervix 


Fig.  726. 


-Escape  of  the  Trunk  through 
the  Vulva. 


FETAL  DYSTOCIA   FROM   FAULTY   PRESENTATION. 


535 


coming  head.  The  first  risk  of  the  child,  death  from  asphyxia,  irrespective  of  com- 
pression of  the  cord  or  detachment  of  the  placenta,  is  due  to  premature  inspiration, 
produced  by  the  contact  of  the  bom  portions  of  the  body  with  the  cooler  outside 
air.  Respiration  causes  aspiration  of  mucus  with  obstruction  of  air-passages.  Ex- 
tension of  one  or  both  arms  is  an  unfortunate  complication,  which  still  further  pro- 
longs the  expulsion  of  the  head ;  because  the  uterus  cannot  grasp  the  breech  so 
firmly  as  it  can  the  head,  and  thus  while  the  fore-waters  still  have  communication 
with  the  rest  of  the  liquor  amnii,  there  is  premature  rupture  of  the  membranes 
from  this  unusual  force  of  uterine  contractions.  Dry  labor  may  ensue.  Frac- 
tures and  dislocations  often  occur  when  interference  is  necessary.  Hematoma  of 
the  stemo-mastoid  and  torticollis  have  also  been  noted  in  connection  with  breech 
delivery. 

Diagnosis. — 


Position  of  Fetus. 


Left  sacro-ante-  |  Sacrum  to  left  acetabulum;  back  to  left  ante- 
rior.    L.  S.  A.    !      rior;  abdomen  to  right  posterior. 

Right  sacro-ante-  i  Sacrum  to  right  acetabulum;  back  to  right 
rior.    R.  S.  A.  anterior;  abdomen  to  left  posterior. 

Right  sacro-pos-  j  Sacrum  to  right  sacro-iliac  joint;  back  to 
terior.    R.  S.  P.  j      right  posterior;  abdomen  to  left  anterior. 

Left  sacro-poste-  j  Sacrum  to  left  sacro-ihac  joint;  back  to  left 
rior.      L.  S.  P.     j      posterior;  abdomen  to  right  anterior. 


Position  of  Fetal  Heart- 
sounds. 


Left  side  of  abdomen, 
opposite  umbilicus. 

Right  side  of  abdomen, 
opposite  umbilicus. 

Right  side  of  abdomen, 
opposite  umbilicus 
and  toward  the  back. 

Left  side  of  abdomen, 
opposite  umbilicus 
and  toward  the  back. 


External  Examination. — If  the  fundus  uteri  is  palpated  the  head  may  be 
recognized  in  that  locality  in  the  first  position  on  the  right  side  and  in  the  second 
position  to  the  left  (Figs.  706  and  715).  The  back  is  recognized  by  its  uniform 
resistance.  On  the  opposite  side  of  the  uterus,  occupied  chiefly  by  liquor 
amnii,  the  resistance  is  much  less  marked.  In  palpating  over  the  pelvic  inlet  we 
encounter  not  the  head  but  a  less  resistant  structure.  The  lower  extremities 
may  be  made  out  in  the  inferior  uterine  segment.  The  fetal  heart  should  be 
heard,  in  the  first  position,  just  to  the  left  of  the  median  line  and  at  the  height 
of  or  a  little  above  the  umbilicus.  In  the  second  position  the  heart  should  be 
heard  on  the  right  side  at  some  distance  from  the  median  line  and  somewhat 
further  back,  the  level  being  the  same  as  in  the  first  position. 

Internal  Examination. — As  a  rule,  the  breech  is  higher  up  at  the  beginning  of 
labor  than  is  the  head  in  vertex  presentation.  The  bag  of  waters  projects  to  quite 
an  extent  into  the  vagina,  sometimes  forming  an  elongated  tumor.  Now  and  then 
the  tension  is  so  great  that  rupture  occurs  with  a  loud  report,  on  the  same  principle 
as  the  bursting  of  a  paper  bag  full  of  air.  As  the  cervix  does  not  perfectly  grasp 
the  presenting  part,  nearly  all  of  the  amniotic  fluid  is  lost  after  the  membranes 
are  ruptured.  When  this  discharge  is  very  rapid,  the  pains  often  decrease  or 
cease  entirely  for  the  time  being.  Meconium  is  often  mixed  with  the  fluid.  In 
palpating  the  presenting  part  we  encounter  a  soft,  smooth,  somewhat  conical  sur- 
face. If  we  assume  this  to  be  the  head,  we  are  unable  to  recognize  sutures,  fon- 
tanelles,  or  hair.  If  we  assume  that  we  have  a  breech  presentation,  we  may  be 
able  to  recognize  the  anus,  the  ischial  tuberosities,  and  the  tip  of  the  coccyx,  above 
which  is  the  triangular  sacrum.  As  labor  advances  the  genitals  may  be  recognized, 
but  even  then  an  attempt  to  distinguish  the  sex  is  by  no  means  easy.  The  anus  will 
feel  like  a  dimple  between  two  skin-covered  elevations.    The  buttock  will  feel  like 


536 


PATHOLOGICAL   LABOR. 


HEAD    MOULDING   IN    BREECH    PRESEN- 
TATION. 


Fig.  727. — Before  Moulding. 


Fig.  728. — After  Moulding. —  {Author's  case.) 


a  soft,  round  tumor,  through  which 
the  great  trochanter  will  offer  its  re- 
sistance. If  the  tip  of  the  coccyx  be 
felt,  the  examining  finger  can  trace 
back  its  connection  with  the  sac- 
rum. The  ischial  tuberosities  and 
the  external  genitals  also  present 
other  important  landmarks.  The 
tip  of  the  coccyx  always  points 
away  from  the  back  of  the  fetus. 
The  heels  and  toes  also,  when  the 
two  feet  present,  will  indicate  the 
position  of  the  fetus. 

Dififerential  Diagnosis.  —  Face 
and  Breech:  Great  care  must  be  ex- 
ercised in  distinguishing  a  face  from 
a  breech  presentation,  for  to  the 
touch  the  similarity  of  the  mouth 
and  the  anus  may  readily  lead  to 
an  erroneous  diagnosis.  The  anus 
lies  in  a  fossa,  while  the  mouth  is 
more  superficially  placed.  If  the 
finger  is  gently  introduced  into  the 
cavity,  the  contraction  and  resist- 
ance of  the  sphincter  ani  give  cer- 
tain evidence  of  a  breech  presenta- 
tion. Foot  and  hand:  The  foot  is 
recognized  by  the  presence  of  the 
heel  and  the  absence  of  the  adduci- 
ble  thumb  and  by  the  toes  being 
nearly  in  a  straight  line.  If  the 
child  is  alive,  the  kicking  move- 
ments also  distinguish  between  feet 
and  hands.  Knee  and  elhow:  The 
patella  in  the  knee  can  usually  be 
distinguished  from  the  olecranon  in 
the  elbow.  In  doubtful  cases  due 
to  oedema,  the  part  should  be  fol- 
lowed up  to  the  trunk.  The  groin 
may  be  differentiated  from  the  ax- 
illa bv  the  absence  of  the  ribs. 


Fig. 


729. — Moulding    of    Skull.- 
collection.) 


■{Author's 


Fig.  730. — Moulding  of  Skull. - 
thor's  collection.) 


-(Au- 


FETAL  DYSTOCIA   FROM   FAULTY   PRESENTATION.  537 

Treatment. — During  pregnancy  we  can  often  convert  the  breech  into  a  vertex 
presentation  by  external  version.  It  will  not  always  be  found  easy,  however, 
to  maintain  the  latter  presentation.  A  common  method  of  accomplishing  this  is 
to  apply  two  long  cylindrical  compresses  of  gauze  to  the  sides  of  the  uterus  and  to 
hold  them  in  place  with  a  firm  abdominal  binder.  I  gave  this  method  a  thorough 
trial  in  the  case  of  a  physician's  wife,  and  each  removal  of  the  binder  resulted  in 
a  return  to  a  breech  presentation.  External  version,  however,  is  more  often 
successful  in  the  beginning  of  the  first  stage,  the  fetus  then  being  manually  held 
in  the  vertex  presentation  until  engagement  occurs.  I  have  succeeded  with 
this  method  in  several  instances  after  labor  has  begun. 

Successful  treatment  can  be  obtained  only  by  a  careful  study  and  appreciation 
in  each  case  of  the  particular  mechanism  of  labor  and  of  the  conditions  under 
which  the  life  of  the  fetus  is  placed  in  danger.  It  should  be  remembered  (i)  that 
labor  is  tedious,  because  the  buttocks  constitute  a  slow  dilator  of  the  cervix,  vagina, 
and  vulva;  (2)  that  the  compressible  trunk  imperfectly  dilates  the  passages,  leav- 
ing much  for  the  after-coming  hard,  incompressible,  and  relatively  large  head  to 
accomplish  in  the  way  of  dilatation ;  (3)  that  the  real  dangers  begin  when  the  um- 
bilicus enters  the  pelvis,  and  are  increased  manifold  when  the  umbilical  cord  and 
head  occupy  the  pelvis  at  one  and  the  same  time.  The  principles  in  the  treat- 
ment of  pelvic  presentation  are :  ( i )  To  prolong  the  first  stage  of  labor.  This  is  to 
secure  full  dilatation  of  the  passages.  We  accomplish  this  by  discouraging  the 
use  of  the  voluntary  forces  and  by  the  use  of  chloroform  if  necessary.  (2)  To  pre- 
serve the  membranes  as  long  as  possible.  This  also  has  for  its  object  the  securing 
of  a  full  dilatation.  To  accomplish  this,  we  make  few  examinations  and  keep 
the  patient  as  quiet  as  possible  in  the  recumbent  position.  The  Germans 
recommend  hydrostatic  bags  or  tampons  in  the  upper  part  of  the  vagina,  but 
I  have  failed  to  appreciate  their  utility.  The  preservation  of  the  membranes 
is'  of  especial  value  in  breech  presentations,  because  the  breech  cannot 
well  dilate  the  cervix,  for  the  later  passage  of  the  firmer  and  harder  head. 
The  soft  parts  are  frequently  lacerated  by  the  after-coming  head  when  the 
breech  has  borne  the  brunt  of  dilating  the  cervix.  (3)  Carefully  to  watch  the 
fetal  heart-sounds  after  the  rupture  of  membrane  and  to  prepare  for  a  rapid 
second  stage.  To  have  everything  ready  for  the  resuscitation  of  an  asphyxiated 
child  and  to  keep  the  position  of  the  fetus,  the  mechanism  of  head  expulsion, 
and  the  dangers  clearly  in  mind.  (4)  Always  to  follow  down  the  fundus.  This 
preserves  head  flexion  and  keeps  the  uterus  closely  applied  to  the  head,  thus  pre- 
venting extension  of  the  arms.  (5)  To  protect  the  perineum  as  in  vertex  cases. 
(6)  When  the  umbilicus  appears,  to  draw  down  the  cord  a  few  inches,  to  place  it 
to  the  rear,  if  possible  opposite  a  sacro-iliac  joint,  to  watch  its  pulsations  and  to 
protect  it  from  longitudinal  stretching.  (7)  To  wrap  the  child  in  a  hot  towel 
(100°  F.)  to  prevent  respiration  from  contact  with  the  air  of  the  lying-in  room 
(70°  F.)  and  to  support  it  well  to  prevent  pressure  on  the  neck.  (8)  As  the 
chin  appears,  to  elevate  the  trunk  and  to  assist  in  the  expulsion  of  the  head 
if  necessary  by  suprapubic  pressure  {expressio  foetus).  Much  can  be  done  at 
this  time  by  urging  the  woman  to  use  her  voluntary  muscles  in  bearing-down. 
If  there  is  much  delay,  one  should  not  hesitate  to  employ  some  form  of  manual 
extraction  of  the  head.  (See  Obstetric  Surgery,  Part  X.)  Should  the  arms  be- 
come extended  along  the  side  of  the  head  or  above  it,  they  must  be  immediately 
brought  down.  (See  Operations,  Part  X.)  Should  the  head  remain  transverse 
at  the  pelvic  outlet,  two  fingers  should  be  placed  on  the  occiput  and  two  fingers 
on  the  malar  bones,  or  one  finger  in  the  mouth,  and,  the  trunk  being  supported 
between  the  forearms,  the  chin  shoiild  be  rotated  to  the  posterior  pelvic  wall. 


538 


PATHOLOGICAL   LABOR. 


FIRST  SHOULDER  POSITION. 
LEFT  SCAPULA  ANTERIOR,  L.  SCAP.  A. 


Fig.  731. — At  the  Pelvic  Inlet. 


(See  Part  X.)  The  trunk  should  not  be  twisted  under  any  circumstances,  in  the 
hope  of  causing  internal  rotation  of  the  head.  Should  the  head  remain  in  a 
transverse  position  in  the  upper  portion  of  the  pelvis,  the  head  should  be 
brought  to  the  pelvic  floor  by  suprapubic  pressure  and  then  the  above  proce- 
dure followed.  That  the  life  of  the  child  may  be  saved  the  head  must  be  born 
within  five  to  ten  minutes  after  the  appearance  of  the  umbilicus.     Sometimes 

the  placenta  is  detached  too  easily,  like- 
wise endangering  the  life  of  the  child. 
Hence  it  is  necessary  to  aid  the  birth  of 
the  head.  If  head  flexion  is  not  pre- 
served, the  chin  will  catch  somewhere  in 
the  pelvis.  The  flexion  should  be  main- 
tained by  firm  continuous  pressure  on 
the  fundus  of  the  uterus.  In  case  there 
is  prolapse  of  the  cord,  the  rapid  delivery 
of  the  child  is  indicated.  If  the  heart- 
beat is  rapid  or  slow,  speedy  birth  is  im- 
perative. If  the  leg  or  foot  presents ,  it  is 
easy  to  hurry  the  labor ;  but  if  the  breech 
presents,  the  acceleration  is  more  diffi- 
cult. It  can  be  done  by  passing  the  finger 
over  the  groin  and  making  traction. 
Some  claim  that  as  soon  as  the  diagnosis 
is  made  one  should  pull  down  one  or  both 
legs.  One  advantage  of  not  doing  so  is 
that  the  breech  is  a  better  dilator  of  the 
cervix  than  is  the  body  with  the  legs  ex- 
tended, and,  generally  speaking,  it  is 
better  to  leave  the  presentation  as  it  is, 
for  fear  that  leg  traction  might  extend 
head  and  arms.  The  first  stage  of  labor 
should  be  entirely  finished  before  the 
second  stage  begins.  We  should  not  in- 
terfere without  some  positive  indication. 
The  forceps  is  seldom,  if  ever,  required  to 
deliver  the  after-coming  head  in  breech 
presentation.     (See  Operations,  Part  X.) 

XI.    SHOULDER  PRESENTATION. 

Synonyms:      Trunk      Presentation; 
Transverse  Position;  Cross-birth. 

Definition. — Shoulder  presentation  is 
so  named  from  the  shoulder  being  the 
presenting  part.  An  absolute  transverse 
position  exists  when  the  long  axis  of  the  fetus  forms  a  right  angle  with  the  long 
axis  of  the  uterus,  and  is  of  rare  occurrence.  It  is  never  present  during  labor.  Any 
position  of  the  fetus  in  which  an  angle  exists  between  the  fetal  and  uterine  long 
axes  is  technically  a  transverse  position,  therefore  obHque  is  really  the  proper  term 
to  designate  the  anomaly.  Unless  the  obHquity  is  so  slight  that  the  ordinary  head 
and  breech  positions  are  assumed  spontaneously  or  through  artificial  aid  during 
labor,  a  transverse  or  oblique  position  is  virtually  one  in  which  the  shoulder  pre- 


FiG.  732. — At  the  Pelvic  Inlet. 


Fig.  733. — Right  Shoulder  in  the  Cer 
vix. 


FETAL  DYSTOCIA   FROM   FAULTY  PRESENTATION. 


539 


SECOND  SHOULDER  POSITION. 
RIGHT  SCAPULA  ANTERIOR,  R,  SCAP.  A. 


sents.  These  positions  are,  therefore,  usually  classified  with  respect  to  the  special 
attitude  of  the  shoulder.  In  shoulder  presentation  the  shoulder  almost  invariably 
becomes  anterior,  and  presents  in  the  cervix  or  vagina  at  an  early  stage  of  the 
labor,  since  it  is  the  most  prominent  and  resistant  part  of  the  trunk.  This  is  due 
to  the  contractions  of  the  uterus  at  the  beginning  of  labor,  although  it  is  conceiv- 
able, and  even  likely,  that  any  of  the  numerous  so-called  trunk  presentations 
should  persist.  Under  the  term  shoulder  presentation,  then,  we  include  all  exist- 
ing trunk  presentations,  such  as  dorsum, 
lateral  plane,  abdomen,  thorax,  neck, 
arm,  elbow,  or  hand.  The  commonest 
form  of  shoulder  presentation  is  the  dor- 
so-anterior,  with  the  head  to  the  left. 
Occasionally  in  this  connection  we  have 
a  compound  presentation,  such  as  hands 
and  feet  or  feet  and  head.  In  all  cases  of 
shoulder  presentation  a  wedge  is  formed, 
its  base  pointing  upward,  made  of  one  of 
the  long  diameters  of  the  head  (4^  to  5^ 
inches — 11.43  to  13.97  cm.),  and  an  ob- 
lique diameter  of  the  trunk  (4I  inches — 
12  cm.)  occupying  the  lower  uterine  seg- 
ment (Fig.  731).  Labor  consequently 
with  a  full-term  child  and  a  pelvis  of 
average  dimensions  becomes  impossible 
without  either  spontaneous  or  artificial 
correction  of  the  malpresentation. 

Frequency.  —  The  proportion  of 
shoulder  presentations  as  given  by  dif- 
ferent statistics  varies  considerably.  At 
one  maternity  the  ratio  may  be  i  to  125 
normal  births,  while  at  another  it  may 
not  exceed  i  in  300.  The  proportion  of 
primiparae  to  multiparae  also  varies,  the 
former  comprising  6  to  27  per  cent,  of 
the  total.  In  2200  cases  of  confinement 
I  found  shoulder  presentation  occurring 
in  12  cases,  0.54  per  cent.,  or  i  in  183 
cases. 

Etiology. — This  differs  entirely  with 
the  parity  of  the  woman.  In  primigra- 
vidae  the  pelvis  in  shoulder  presentations 
is  usually  contracted.  As  occasional  con- 
tributory factors  may  be  mentioned  vari- 
ous conditions  which  predispose  to  faulty 
positions  in  general — hydramnios,  mon- 
strosities, malformation  of  the  uterus,  twins.  In  multigravidse  shoulder  pre- 
sentations often  come  about  through  relaxation  of  the  abdominal  walls,  and 
especially  in  pendulous  abdomen.  The  causes  mentioned  as  obtaining  in  primi- 
gravidae  are  also  operative  here  to  some  extent.  Unusual  mobility  of  the  fetus 
is  another  condition  believed  to  favor  the  persistence  of  the  oblique  position 
In  the  fetus  immaturity — by  reason  of  the  weak  muscles,  the  relatively  large 
amount  of  liquor  amnii,  and  the  shape  of  the  fetal  ellipse  in  the  premature  fetus — 


Fig.  734. — At  the  Pelvic  Inlet. 


Fig.  735. — At  the  Pelvic  Ixlet. 


Fig.   736. — Left    Shoulder  in  the  Cer- 
vix. 


540 


PATHOLOGICAL   LABOR. 


THIRD  SHOULDER  POSITION. 

Right  Scapula  posterior,  R.  Scap.  p. 


is  the  great  cause  of  shoulder  presentation.  (Page  423.)  Death  and  maceration 
of  the  fetus  and  multiple  pregnancy  for  like  reasons  are  causes.  (Page  423.)  In 
the  parturient  tract  pelvic  deformity,  excessive  pelvic  obliquity,  and  excessive 
right  lateral  obliquity  of  the  uterus  are  causes  by  interfering  either  with  the  proper 
attitude  of  the  child  or  the  ready  engagement  of  the  head  in  the  pelvic  inlet.  For 
the  same  reason  placenta  prasvia,  lax  abdominal  walls,  as  in  hanging  belly,  and 
an  excessive  amount  of  liquor  amnii  may  result  in  shoulder  presentation.     This 

malpresentation  is  seven  times  more  fre- 
quent in  multigravidag  than  in  primi- 
gravidae.  Hydrocephalus  or  enlarge- 
ment of  the  fetal  head  from  any  cause, 
since  then  it  cannot  engage  in  the  pelvic 
inlet;  fetal  monstrosities  and  extreme 
mobility  of  the  fetus  from  any  cause; 
tumors  of  the  pelvis  or  uterus,  kyphotic 
spine  and  exostoses  of  the  pelvic  bones ; 
tight  lacing  during  pregnancy,  which  de- 
creases the  depth  of  the  uterus  while  in- 
creasing the  width ;  jars  or  traumatism  of 
any  kind — any  one  of  these  may  offer 
cause  for  this  faulty  presentation. 

Positions  and  Relative  Frequency. — 
Shoulder  positions  are  named  from  the 
relation  which  a  scapula — part  of  the 
fetus — bears  to  one  of  the  four  cardinal 
points  of  the  pelvis.  It  should  be  re- 
membered that  right  and  left  never  refer 
to  the  scapulae,  but  always  to  the  right 
and  left  side  of  the  pelvis;  thus  in  the 
right  scapula  anterior  we  mean  that  the 
scapula  is  to  the  mother's  right  and  an- 
terior, no  consideration  being  taken  of 
the  fact  that  the  left  scapula  of  the  fetus 
presents. 

I.   Left    scapula    anterior,    Scapula 
laeva  anterior,  L.  Scap.  A.  (Fig.  731). 

II.  Right  scapula  anterior.  Scapula 
dextra  anterior,  R.  Scap.  A.  (Fig.  734). 

III.  Right  scapula  posterior.  Scapula 
dextra  posterior,  R.  Scap.  P.  (Fig.  737). 

IV.  Left  scapula  posterior,  Scapula 
laeva  posterior,  L.  Scap.  P.  (Fig.  740). 

Left  scapula  anterior  is  the  most  fre- 
quent position. 

Mechanism  and  Course  of  Labor. — 
We  may  say  there  is  practically  no  mech- 
anism of  labor  in  shoulder  presentation.  It  is  safer  to  look  upon  labor  as  im- 
possible without  artificial  aid  than  to  trust  to  a  spontaneous  termination  of  the 
complication.  The  usual  steps  in  unaided  cases  are  impaction  of  the  shoulder; 
ascension  of  the  contraction  ring;  fetal  death  from  prolonged  pressure  and 
maternal  death  from  rupture  of  the  uterus  or  exhaustion.  While  this  is  true, 
still  under  certain  conditions  a  shoulder  presentation  has  been  known  to  terminate 


F-iG.  737. — At  the  Pelvic  Inlet. 


Fig.  738. — At  the  Pelvic  Inlet. 


fi 


Fig.  739.- 


-RiGHT  Shoulder  in  the  Cer- 
vix. 


FETAL  DYSTOCIA   FROM   FAULTY  PRESENTATION. 


541 


FOURTH  SHOULDER    POSITION. 
LEFT  SCAPULA    POSTERIOR,  L.  SCAP.   P. 


Fig.  740. — -At  the  Pelvic  Inlet. 


spontaneously,  in  three  ways,  viz.:  (i)  Spontaneous  rectification  or  spon- 
taneous version;  (2)  spontaneous  evolution;  (3)  doubled  fetus,  partus  condu- 
plicato  cor  pore. 

1.  Spontaneous  Rectification  and  Verston. — The  term  spontaneous  rectifica- 
tion is  usually  confined  to  instances  in  which  the  cephalic  extremity  of  the  fetus 
is  brought  into  the  lower  uterine  segment,  and  the  term  spontaneous  version 
to  those  cases   in  which  the   breech  is 

brought  to  the  pelvic  inlet.  Spontaneous 
rectification  is  of  frequent  occurrence, 
and  is  often  observed  in  the  latter  part 
of  gestation  or  in  the  preparatory  or  first 
stage  of  labor.  Spontaneous  version  is  of 
less  frequent  occurrence,  as  the  breech 
is  not  so  frequently  substituted  for  the 
shoulders  at  the  pelvic  inlet  as  is  the 
head.  The  requirements  for  spontaneous 
version  are  a  rigid  fetus,  viz.,  living  and 
strong;  irregular  and  strong  uterine  con- 
tractions, confined  to  the  fundus,  where- 
by the  breech  is  driven  down  into  the 
lower  uterine  segment.  Spontaneous 
version  is  most  apt  to  take  place  in  mul- 
tiparse  whose  tissues  are  lax.  After  the 
bag  of  waters  has  ruptured,  spontaneous 
version  is  seldom  encountered,  although 
the  phenomenon  is  sometimes  seen  im- 
mediately after  rupture  before  the  am- 
niotic fluid  has  escaped  to  any  great  ex- 
tent. When  the  waters  have  mostly 
escaped,  the  tendency  of  the  uterus  is  to 
grasp  the  fetus  firmly,  so  that  the  shoul- 
der presentation  becomes  confirmed.  The 
opposite  phenomenon  is  sometimes  seen, 
in  which  a  normal  position  of  the  child 
becomes  transformed  by  uterine  contrac- 
tions into  a  shoulder  presentation.  These 
so-called  secondary  shoulder  positions 
are  of  very  infrequent  occurrence.  Spon- 
taneous rectification  and  version  are 
both  probably  due  to  uterine  contrac- 
tions, but  another  factor  assists,  such  as 
the  antero-lateral  pressure  of  the  pa- 
tient's thighs  as  she  sits  or  throws  her- 
self into  certain  postures,  e.  g.,  kneeling 
or  sitting.  After  spontaneous  version  or 
rectification  has  occurred,  the  mechanism  is  that  of  a  head  or  breech  presentation. 

2.  Spontaneous  Evolution  (Fig.  543). —  When  a  shoulder  presentation  be- 
comes confirmed,  a  favorable  termination  of  labor  is  still  possible  if  the  pelvis  is 
ample,  the  pains  are  strong,  and  the  fetus  is  small.  In  these  cases  the  shoulder, 
forced  into  the  pelvic  inlet,  follows  the  general  law  of  rotation  and  turns  forward. 
It  then  comes  to  lie  beneath  the  symphysis,  the  two  fetal  poles  being  closely 
approximated.     The  shoulder  is  followed  by  the  subjoined  half  of  the  thorax,  the 


At 


Fig.  741. — At  the  Pelvic  Ixlet. 


Fig.  742. — Left 


Shoulder 
vix. 


IN  THE  Cer- 


542 


PATHOLOGICAL  LABOR. 


Fig.  746. 
Figs.   743  to  746. — The    Four    Stages   of    Spon- 
taneous Evolution. 


buttocks,  the  opposite  shoulder, 
and  finahy  the  head.  This  pro- 
cess may  require  but  very  Httle 
time,  and  even  a  soHtary  con- 
traction is  known  to  have  been 
sufficient.  This  spontaneous  ter- 
mination of  shoulder  presenta- 
tion occurs  in  about  8  per  cent, 
of  all  cases  if  unusually  small 
children,  second  twins,  prema- 
ture births,  etc.,  are  included. 
In  a  series  of  immature  living 
children  the  proportion  is  still 
higher,  and  some  authors  do  not 
even  class  these  deliveries  as 
pathological.  The  stages,  then, 
in  the  accomplishment  of  spon- 
taneous evolution  are:  (i)  com- 
pression of  the  fetus;  (2)  descent 
(Fig.  743) ;  (3)  engagement  of  the 
anterior  shoulder  under  the  pu- 
bic arch  (Fig.  744);  (4)  driving 
out  of  the  podalic  extremity  of 
the  fetus  over  the  posterior  wall 
of  the  parturient  tract  (Fig.  745)  i 

(5)  delivery  of  the  posterior 
shoulder    and    arm    (Fig.    745); 

(6)  delivery  of  the  after-coming 
head  (Fig.  746).  Excessive  lat- 
eral flexion  of  the  fetus  is  neces- 
sary for  the  accomplishment  of 
spontaneous  evolution.  Unless 
all  conditions  are  most  favorable 
for  birth,  the  case  will  end  in  fetal 
impaction  and  death  of  the  fetus. 

3.  Doubled  Fetus  {Partus 
Condnplicato  Cor  pore) .  — When 
spontaneous  evolution  occurs  in 
very  small  yielding  fetuses,  the 
approximated  head  and  but- 
tocks may  pass  through  the  pel- 
vis side  by  side,  rotation  failing 
to  occur.  This  so-called  partus 
condnplicato  cor  pore  is  extremely 
rare.  The  fetus's  head  and  body 
together  enter  the  pelvis  with 
the  prolapsed  shoulder  in  ad- 
vance. There  should  be  rotation 
of  this  shoulder  to  the  pubic 
arch,  but  the  mechanism  of  this 
process  is  scarcely  noticeable, 
since  if  it  is  possible  for  it  to  take 


FETAL  DYSTOCIA   FROM   FAULTY  PRESENTATION. 


543 


Fig.  747.— Frozen  Section  of  a  Neglected  Shoulder 
Presentation.  Woman  died  in  the  second  stage  of 
labor.  Shows  first  stage  of  spontaneous  evolution. — 
{Chiara.) 


place  at  all,  the  fetus  must  be  very  soft  and  small.  In  this  process  the  head  and 
body  are  delivered  together,  followed  by  buttocks  and  legs,  the  second  arm  lying 
between  the  head  and  breech.  The  conditions  necessary  for  delivery  by  a  doubled 
fetus  are  a  roomy  pelvis  and  a  small,  macerated,  dead  or  premature  fetus.  It  is 
an  extremely  rare  termination. 

The  preceding  terminations  of  shoulder  presentation  are  exceptional,  and  in 
the  great  majority  of  cases 
nature  is  unequal  to  the  task 
of  expelling  the  fetus.  If 
labor  in  a  shoulder  presenta- 
tion begins  with  weak  pains 
and  early  rupture  of  the  mem- 
branes, the  contractions  re- 
maining feeble  after  the  latter 
event,  such  a  state  of  affairs 
may  persist  for  days  until  the 
cervix  is  fully  dilated.  Or  we 
may  sometimes  see  rupture  of 
the  membranes  followed  by 
violent  contractions  which 
cause  rupture  of  the  lower 
segment  of  the  uterus  within 
a  few  hours.  Under  any  cir- 
cumstances the  long  sojourn 
of  the  fetus  in  the  maternal 
passages,  often  inevitable  in 

shoulder  presentation,  is  frequently  followed  by  maceration,  especially  when 
death  has  occurred  early  in  labor.  Maceration,  by  rendering  the  child  more 
compressible,  is  sometimes  the  occasion  of  spontaneous  ending  of  labor. 

Diagnosis. — Before  labor  abdominal  palpation  usually  renders  the  diagnosis 
simple.  During  labor  we  find  the  cervix  high  up  in  the  pelvis  and  irregular 
formation  of  the  bag  of  membranes.  When  uncertainty  exists,  one  must  admin- 
ister chloroform  and  pass  the  whole 
hand  into  the  vagina  to  make  a 
positive  diagnosis.  The  shoulder 
is  to  be  differentiated  from  the 
breech  (page  536);  the  elbow  from 
the  knee  (page  536) ;  the  hand  from 
the  foot  (page  536).  Inspection 
alone  will  often  reveal  the  nature 
of  the  case,  as  the  transverse  diam- 
eter of  the  uterus  exceeds  the  longi- 
tudinal and  the  outline  is  not  sym- 
metrical. As  a  rule,  the  fetal  back 
lies  anterior.  Then  the  round,  hard 
head  can  be  felt  in  one  iliac  fossa 
and  the  soft,  irregular  breech  in  the 
opposite  side  of  the  mother's  abdomen  high  up  (Fig.  201).  The  hne  of  the  back 
may  be  traced  between  the  two.  These  points  may  be  observed  before  labor  or 
in  its  early  stage.  But  at  a  more  advanced  stage,  as  lateral  flexion  of  the  child 
increases,  the  head  would  almost  appear  to  join  the  breech  at  a  right  angle. 
When  the  resisting  back  lies  posterior,  it  cannot  be  felt  by  palpation.      By  vaginal 


Fig.  748. — Neglected  Shoulder  Presenta- 
tion. Left  Scapulo-anterior  Position. 
Death  of  fetus  and  oedema  and  excoriation  of 
the  right  shoulder. —  (Schaeffer.) 


544 


PATHOLOGICAL  LABOR. 


examination  the  dependent  part  of  the  bag  of  waters  gives  a  sensation  often 
likened  to  that  of  a  glove-finger;  the  head  cannot  be  felt;  if  the  shoulder  presents, 
its  rounded  contour  may  be  felt  as  well  as  the  axillary  fossa;  the  ribs  may  be 
traced  near  at  hand  and  also  the  acromion,  clavicle,  and  scapular  spine. 


Position  of  Fetus. 


PosiTioK  OF  Fhtal  Heart- 
sounds. 


Left  Scap. -ante- 
rior.  L.Scap.A. 

Right  Scap. -ante- 
rior. R.  Scap. 
A. 

Right  Scap. -pos- 
terior. R. Scap. 
P. 

Left  Scap. -poste- 
rior. L.  Scap. 
P. 


Head  in  left  ihac  fossa,  back  anterior;  extremi- 
ties on  right  side,  in  upper  part  of  abdomen. 

Head  in  right  iUac  fossa,  back  anterior;  ex- 
tremities on  left  side,  in  upper  part  of  abdo- 
men. 

Head  in  right  iliac  fossa,  back  posterior;  ex- 
tremities on  left  side,  in  upper  part  of  abdo- 
men. 

Head  in  left  iliac  fossa,  back  posterior;  extremi- 
ties on  right  side,  in  upper  part  of  abdomen. 


Left  side  of  abdomen, 
below  umbilicus. 

Right  side  of  abdomen, 
below  umbilicus. 

Right  side  of  abdomen, 
below  umbilicus  to- 
ward the  rear. 

Frequently  cannot  be 
heard.  Left  side  to 
the  rear. 


Prognosis. — In  cases  left  to  themselves  the  prognosis  is  grave  for  both  mother 
and  child.  With  intervention,  the  outlook  varies  with  the  stage  of  labor  and 
other  factors.  If  the  case  is  seen  early,  the  position  may  be  transformed  from 
the  oblique  to  the  vertical,  especially  if  the  bag  of  waters  is  intact;  while  if  the 
latter  can  be  preserved  until  the  cervix  is  fully  dilated,  there  is  a  good  chance  of 
extracting  the  child  alive.  The  outlook  for  the  mother  is  prejudiced  only  by  the 
added  danger  from  atonia,  hemorrhage,  and  infection  from  manipulations.  It 
must  be  remembered,  however,  that  rupture  of  the  uterus  may  occur  during 
the  performance  of  embryotpmy.  The  prognosis  will  depend  on  the  operation 
undertaken,  since  natural  termination  of  shoulder  presentation  is  not  the  rule. 
When  the  presentation  is  rectified  early,  there  is  a  good  outlook  for  mother  and 
child.  Neglected  cases  will  result  in  death  of  both.  Dangers  to  the  child  come 
from  compression  of  the  brain  centers,  vessels  of  the  neck,  or  umbilical  cord. 
Injury  of  the  child  is  liable  to  occur  during  operation.  The  mother  may  die  of 
sepsis,  exhaustion,  rupture  of  the  uterus,  or  hemorrhage.  Conclusions:  The 
prognosis  depends  upon:  (i)  the  stage  of  labor  at  which  the  complication  is 
recognized;  (2)  the  time  that  elapses  before  the  correction  of  the  mal- 
presentation ;  (3)  the  time  that  has  elapsed  since  the  membranes  ruptured,  and 
the  quantity  of  liquor  amnii  still  remaining  in  the  uterus ;  (4)  the  condition 
of  the  uterus  and  cervix,  especially  as  regards  thinning  of  the  lower  uterine 
segment,  and  ascent  of  the  contraction  ring;  (5)  prolapse  of  the  cord  as  a  com- 
plication. A  neglected  shoulder  presentation  results  in  a  gradual  escape  of  all 
the  liquor  amnii,  contraction  and  retraction,  a  tetanic  or  inert  condition  of 
the  uterus  with  or  without  uterine  rupture,  exhaustion  and  death  of  both  mother 
and  fetus. 

Treatment. — All  delay  is  dangerous,  and  the  sooner  the  malpresentation  is 
corrected  by  external,  combined,  or  internal  version,  the  better  the  prog- 
nosis. If  the  shoulder  is  already  impacted,  decapitation  of  the  fetus  must  be 
performed  or  some  other  method  of  removing  the  child  should  be  undertaken  at 
once.  Laparotomy,  with  the  Caesarean  or  Porro  operation,  is  certainly  safer  in 
many  neglected  cases  than  a  difficult  decapitation.     (See  Part  X.) 


FETAL  DYSTOCIA   FROM   FAULTY  POSITION.  545 


FETAL  DYSTOCIA  FROM  FAULTY  POSITION. 

XI!.  PERSISTENT    OCCIPITO-POSTERIOR    POSITION. 

Definition. — The  vertex  presentation  in  which  backward  rotation  of  the 
occiput  occurs  in  the  first  and  second  positions  or  in  which  a  permanent  occipito- 
jjosterior  position  obtains  in  the  third  and  fourth  positions.  As  a  rule,  labor  is 
prolonged  in  these  cases,  partly  because  the  head  does  not  flex  as  it  ought  to  on 
its  entrance  into  the  pelvis,  and  consequently  does  not  readily  descend,  and 
partly  on  account  of  the  protracted  internal  rotation  (Fig.  750). 

Frequency. — This  is  variously  stated  as  from  i  to  4  per  cent.  In  2200  labors 
I  found  that  persistent  occipito-posterior  position  occurred  in  89  cases,  or  4.04 
per  cent.;  46,  or  51.68  per  cent.,  were  in  primiparae;  2>3'  or  37.07  per  cent.,  in 
multipar.Te ;   and  10,  or  11.23  P^r  cent.,  were  of  unknown  para. 

Etiology. — The  most  common  cause  is  incomplete  flexion  of  the  head  whereby 
some  other  part  of  the  head,  such  as  the  forehead,  first  meets  the  resistance  of 
the  pelvic  floor,  and  is  deflected  anteriorly.  This  throws  the  occiput  into  the 
hollow  of  the  sacrum.  In  other  cases  the  cause  may  be  found  in  a  defect  in  the 
resistance  of  the  pelvic  floor,  as  in  the  birth  of  the  second  twin  w^hen  the  pelvic 
floor  has  been  stretched  by  the  birth  of  the  first ;  in  old  and  extensive  lacerations 
of  the  pelvic  floor ;  in  disproportion  between  the  head  and  floor,  as  in  very  roomy 
pelves,  or  in  undersized  heads;  in  uterine  and  abdominal  inertia;  in  obstruction 
to  forward  rotation  of  the  vertex,  as  in  prolapse  of  the  hand  or  foot  anteriorly; 
in  pelvic  deformity,  as  in  justo-minor  or  k^-^photic  pelves;  or  in  hydrocephalus  of 
the  fetal  head.  In  these  cases  accommodation  or  adaptation  results  in  a  pos- 
terior position  of  the  vertex.  Sometimes  in  cases  in  which  there  is  a  slight 
disturbance  of  flexion  and  the  occiput  first  touches  the  floor,  there  is  rotation 
backward  of  the  occiput  because  the  fronto-occipital  diameter  engages  and  it  is 
impossible  for  the  head  to  rotate  from  one  oblique  diameter  through  the  shorter 
transverse  to  the  other  oblique. 

Mechanism. — (Compare  Vertex  Presentation,  Part  IV.)  To  understand 
the  mechanism  of  labor,  careful  comparison  must  be  made  between  the  lower  an- 
terior and  posterior  wall  of  the  parturient  tract.  The  anterior  wall  of  the  pelvis, 
namely,  the  symphysis,  is  i§  inches  (3.81  cm.)  to  2  inches  (5.08  cm.).  The  dis- 
tance from  the  junction  of  the  neck  with  the  trunk  to  the  vertex  is  about  3  inches 
(7.62  cm.),  hence  in  occipito-anterior  position  the  head  reaches  the  pelvic  floor 
and  extends  through  the  vulval  orifice  without  the  trunk  necessarily  entering  the 
pelvis  until  the  head  is  completely  delivered.  The  posterior  wall  of  the  pelvis, 
from  promontory  of  sacrum  to  coccyx,  is  5  inches  (12.7  cm.),  and  the  pelvic  floor, 
when  distended,  from  coccyx  to  edge  of  perineum  is  also  5  inches  (12.7  cm.),  raak- 
ing  10  inches  (25.4  cm.)  from  promontory  to  perineum.  Hence  for  the  vertex  to 
reach  the  pelvicTloor  in  the  posterior  position  the  neck  must  be  greatly  elongated 
or  the  trunk  must  enter  the  pelvis  with  the  head.  If  the  latter  occurs,  subsequent 
impaction  is  liable  to  take  place,  for  we  will  then  have  at  the  pelvic  outlet  a  pre- 
senting part  whose  antero-posterior  diameter  is  made  up  of  the  fronto-mental 
diameter  of  the  fetal  head  (3 J  inches — 8.25  cm.)  and  the  dorso-stemal  diameter 
of  the  fetal  trunk  (3!  inches — 9.5  cm.),  making  together  7  inches  (17.78  cm.)  to 
pass  through  the  lower  part  of  the  pelvis  (Fig.  750).  In  spite  of  the  foregoing, 
spontaneous  termination  sometimes  occurs.  The  brow  engages  under  the  sym- 
physis; the  perineum,  tremendously  distended,  retracts  over  the  occiput;  the 
latter,  in  an  extreme  state  of  flexion,  sometimes  with  an  entire  loss  of  perineum 
35 


546 


PATHOLOGICAL   LABOR. 


Fig.  749. — Diagram  Explanatory  of  the  Mechanism 
OF  Persistent  Occipito-posterior  Position  of  the 
Vertex. 


and  anterior  rectal  wall,  extends  and  is  bom.  The  nape  of  the  neck  then  rests 
upon  the  retracted  and  lacerated  perineum  and  the  supraorbital  ridges,  eyes,  nose, 
and  mouth  appear  under  the  symphysis  and  the  head  is  born  by  extension.  Per- 
sistent occipito-posterior  position  is  also  known  as  "face  to  pubis."    When  natural 

expulsion  takes  place,  as 
has  been  said,  the  face 
passes  under  the  symphysis 
and  the  occiput  makes  its 
way  over  the  perineum. 
This  process  is  not  an  easy 
one  and  necessitates  vigor- 
ous contractions,  lax  ma- 
ternal soft  parts,  and  head 
of  ordinary  size.  The  head 
moulding  results  in  very 
much  shorter  occipito -fron- 
tal and  occipito-mental  di- 
ameters with  correspond- 
ing lengthening  of  the 
suboccipi  to -bregma  tic 
(Fig.  752).  Before  passing 
through  the  outlet  the  head 
becomes  well  flexed.  After 
the  head  is  bom  external 
rotation  (internal  rotation 
of  the  shoulders)  occurs, 
after  which  the  body  is 
bom.  If  flexion  be  prevented,  the  head  may  rarely  come  down  into  the  pelvis  in 
a  state  of  extension  and  there  exists  a  brow  or  face  presentation.  Or,  again,  the 
head  only  partially  flexed  may  enter  the  pelvis,  and  after  reaching  the  floor  there 
may  be  partial  rotation  and  the  head  become  fixed  in  the  transverse  diameter  of 
the  cavity  of  the  pelvis  (Deep  Transverse 
Position  of  the  Head,  page  553.) 

Diagnosis. — In  palpation  of  the  mater- 
nal abdomen  at  the  beginning  of  labor  the 
fetal  limbs  but  not  the  back  may  be  felt, 
especially  if  the  parietes  are  lax  and  thin, 
and  the  head  may  be  perceptible  above  the 
brim.  The  heart-sounds  are  heard  between 
the  ribs  and  the  crest  of  the  ilium.  By  vag- 
inal examination  the  head  may  be  felt 
through  the  fomices,  and  later  on,  when 
the  cervix  is  sufficiently  dilated,  the  pos- 
terior fontanelle  is  in  the  posterior  part  of 
the  pelvic  cavity,  while  the  sagittal  suture 
is  in  the  line  of  an  oblique  diameter.  In  the 
first  stage  the  pains  are  not  infrequently 
irregular  and  abnormal. 

Prognosis. — The  dangers  to  the  mother  are  prolonged  labor,  exhaustion,  and 
even  death.  Severe  lacerations  of  the  pelvic  floor  are  the  rule.  In  impaction 
pressure  necrosis,  sepsis,  and  shock  of  operation  may  occur.  The  mortality  for 
the  child  is  about  10  per  cent.     The  dangers  are:  asphyxia  from  prolonged  com- 


FiG.    750. — Persistent    Occipito-pos- 
terior Position. 


FETAL  DYSTOCIA   FROM   FAULTY  POSITION. 


547 


HEAD  MOULDING   IN    PERSISTENT  OC- 
CIPITO-POSTERIOR  POSITION. 


pression  or  premature  separation  of  the  placenta;  cerebral  compression,  and 
pressure  on  the  cord. 

In  my  89  cases  already  referred  to,  the  maternal  mortality  was  3  cases,  or 
3.38  percent.  Regarding  the  fetal  prognosis,  79,  or  88.76  per  cent.,  lived;  7,  or 
7.86  percent.,  were  still-bom;  and  the 
result  for  3,  or  3.38  per  cent.,  was  not 
recorded.  In  the  89  cases  referred  to 
above,  the  method  of  delivery  was  by 
natural  forces  in  43  cases;  forceps  in 
41 ;  version  in  2  ;  craniotomy  in  i  case, 
and  symphyseotomy  in  i  case. 

Treatment.  —  Prophylactic  :  The 
preventive  treatment  of  this  quite 
common  and  serious  complication  of 
labor  promises  very  little  indeed,  be- 
cause we  are  unable  to  remedy  the 
anatomical  cause  of  the  condition 
found  in  the  fetus,  pelvis,  or  maternal 
soft  parts.  When  the  diagnosis  of  oc- 
cipito-posterior  position  is  made  in 
pregnancy,  it  has  been  proposed  that 
the  more  favorable  anterior  position 
shall  be  obtained  by  external  manipu- 
lation through  the  anterior  abdominal 
wall.  This  is  a  refinement  of  abdom- 
inal palpation  which  I  believe  to  be 
theoretical  in  the  hands  of  most,  if  not 
all,  obstetricians.  Postural  prophyl- 
axis, on  the  other  hand,  I  believe 
offers  some  hope  in  cases  in  which  the 
anatomical  influences  in  fetus,  pelvis, 
or  maternal  soft  parts  are  not  too 
strong.  In  instances  in  which  there 
is  reason  to  suspect  this  complication 
the  patient  may  be  instructed  to  as- 
sume the  knee-elbow  position  for  five 
or  six  minutes  morning  and  evening 
for  a  fortnight  or  even  longer  preced- 
ing labor.*  This  to  be  followed  by  the 
lateral  posture.  I  have  found  in  pri- 
vate practice  that  it  is  often  a  physical 
impossibility  for  patients  to  remain 
more  than  a  minute  or  two  in  the 
knee-chest  position  by  reason  of  the 
intense  cerebral  congestion  and  dis- 
comfort produced.  In  such  a  case  in 
the  latter  part  of  pregnancy  and  dur- 
ing the  first  and  second  stages  of  labor  I  have  the  woman  placed  in  an  exaggerated 
lateral  prone  position  with  a  pillow  or  several  sheets  under  the  lower  buttock  in 
order,  as  far  as  possible,  to  reverse  the  condition  of  the  dorsal  position.  The  choice 
of  side  for  the  patient  to  lie  upon  is  the  one  toward  which  the  occiput  points.  (See 
*  Reynolds:  "Practical  Midwifery,"  page  211,  1892. 


Fig.   751. — Before  Moulding. 


Fig.  752. — After  Moulding.  Note  depres- 
sion at  anterior  fontanelle  caused  by  the 
pubic  arch. 


548 


PATHOLOGICAL  LABOR. 


Operations,  Part  X.)  Operative:  It  should  be  clearly  understood  that  operative 
interference  in  occipito-posterior  position  is  not  to  be  undertaken  until  labor  has 
advanced  to  a  point  at  which  the  interests  of  fetus  or  mother  demand  interven- 
tion. It  must  be  remembered  that  operation  is  applicable  only  to  persistent 
cases  of  this  kind;  that  most  of  the  originally  occipito-posterior  positions  ter- 
minate anteriorly  spontaneously,  and  that  only  between  one  and  four  per  cent,  of 
all  vertex  positions  result  in  persistent  posterior  positions,  the  remaining  being 
either  originally  anterior  positions  or  terminating  spontaneously  as  such.  Before 
deciding  upon  interference  in  all  cases  of  delayed  labor  at  the  pelvic  inlet  I  always 
make  a  thorough  examination  under  chloroform,  introducing  the  whole  hand  if 
necessary  to  ascertain  the  presentation  and  position,  and  secure  flexion  or  exten- 
sion as  the  case  may  be.  For  con- 
venience' sake  I  am  accustomed  to 
divide  all  of  these  cases  into  three 
classes:  (i)  High  cases,  in  which  the 
vertex  is  still  above  the  pelvic  inlet 
and  not  engaged;  (2)  medium,  in 
which  the  vertex  is  fully  engaged  but 
occupies  the  upper  part  of  the  pelvis 
and  has  not  reached  the  pelvic  floor; 
(3)  low  cases,  in  which  the  occiput 
rests  on  the  pelvic  floor  and  possibly 
distends  the  perineum. 

I.  High  Cases. — This  is  the  most 
infrequent  of  the  three  classes,  for  in 
the  majority  of  cases  the  natural 
powers  possess  strength  enough  to 
engage  the  head,  and  only  subse- 
quently, by  reason  of  the  malposi- 
tion and  excessive  force  required,  do 
the  powers  fail.  Fortunate  it  is  that 
this  is  the  case,  since  this  class  car- 
ries with  it  the  worst  prognosis  under 
operative  treatment.  No  serious 
disproportion  existing  between  the 
fetus  and  pelvis,  we  have  at  our  com- 
mand four  procedures  for  the  man- 
agement of  these  cases:  (i)  Rotation 
of  the  back  of  the  fetal  ellipse  to  the 
front  by  external  manipulation,  fol- 
lowed by  the  application  of  the  forceps;  (2)  rotation  of  the  vertex  from  the  pos- 
terior to  the  anterior  position  by  internal  manual  means,  followed  by  the  use  of 
the  forceps;  (3)  the  application  of  the  forceps  without  previous  attempts  at 
anterior  rotation  of  the  occiput;  (4)  internal  podalic  version  followed  by  breech 
extraction,  (i)  External  manual  rotation:  The  possibility  under  favorable  con- 
ditions— namely,  intact  membranes  and  thin  abdominal  walls — of  rotation  of 
the  occiput  forward  by  external  manipulation  must  be  granted,  but  such  a 
theoretical  refinement  of  obstetrical  palpation  can  scarcely  be  of  much  practical 
value.  (2)  Internal  manual  rotation:  Anterior  rotation  of  the  occiput  by  means 
of  the  hand  passed  into  the  uterus  and  grasping  the  head  or  shoulders  and 
allowing  the  anterior  position  to  terminate  spontaneously,  or  delivering  imme- 
diately with   the   forceps,  is   the   favorite   treatment   with   many  operators  in 


Fig.  753. — Persistent  Occipito-posterior 
Position  of  the  Head.  R.  O.  P.  Pro- 
longed labor;  secondary  inertia;  rest;  strych- 
nia; spontaneous  delivery  with  anterior  ro- 
tation of  the  occiput. —  {From  a  tracing. 
Emergency  Hospital,  October  7,  1892.) 


FETAL  DYSTOCIA   FROM   FAULTY  POSITION.  549 

America,  and  by  some  used  to  the  exclusion  of  other  methods  of  treatment. 
I  have  been  more  successful  with  other  methods,  and  I  am  convinced  after 
repeated  trials  that  the  mortality  with  this  method  equals  that  of  internal 
podalic  version,  for  the  reason  that  successfully  to  carry  out  the  anterior  rotation 
the  hand  must  be  used  not  only  to  rotate  the  head,  else  it  will  immediately 
return  to  its  malposition,  but  it  must  be  passed  up  to  rotate  the  shoulders 
as  well.  This  grasping  of  the  fetal  body  I  have  foxmd  disturbs  the  circulatory 
equilibrium  of  the  fetus,  favors  intrauterine  asphyxia,  and,  unless  the  fetus 
is  immediately  extracted,  intrauterine  death  ensues.  Should  this  method  of 
correction  be  selected,  it  should  always  be  performed  bimanually,  one  hand 
upon  the  anterior  abdominal  wall  assisting  in  the  work  of  the  internal  hand. 
The  operation  can  often  be  more  readily  performed  with  the  patient  in  the 
exaggerated  left  lateral  prone  posture,  and  lying  upon  that  side  of  the 
pelvis  around  the  segment  of  which  we  desire  the  occiput  to  rotate.  (See 
Part  X.)  If  the  fetal  back  and  occiput  are  directly  to  the  rear,  and  there 
is  thus  no  choice  of  sides  for  the  patient  to  lie  on,  the  exaggerated  left  lateral 
prone  posture  will  be  found  the  most  convenient  for  permitting  the  use  of 
the  right  hand  internally.  (3)  Forceps:  The  application  of  the  forceps  without 
previous  attempts  at  antenor  rotation  of  the  occiput.  Both  theoretically 
and  practically  .  I  believe  this  method  will  give  better  results  as  far  as  fetal 
mortality  and  morbidity  are  concerned,  and  equally  as  good  results  for  the 
mother  as  version.  The  difficulties  and  dangers  of  a  high  forceps  operation 
in  this  as  in  other  presentations  and  positions  must  ever  be  kept  in  mind,  and 
so  great  are  these  dangers  that  I  would  recommend  this  method  of  treatment 
only  to  those  thoroughly  familiar  with  the  technique  of  a  high  forceps  operation. 
For  those  of  limited  experience  in  high  forceps  operations  version  will  prove 
the  safer  operation  for  the  mother,  although  carrying  with  it  a  high  fetal  mor- 
tality. Of  course,  the  usual  contraindications  for  version  always  hold  good — 
namely,  escape  of  the  liquor  amnii,  tetanic  uterine  contractions,  and  dangerous 
thinning  of  the  lower  uterine  segment.  It  is  in  these  cases  particularly  that 
no  aesthetic  reason  should  prevent  our  perforating  the  head  of  a  dead  fetus. 
Usually  it  is  not  wise  to  attempt  an  adaptation  of  the  forceps  under  such 
conditions  to  the  sides  of  the  fetal  head, — namely,  the  cephalic  application, — 
but  to  apply  the  instrument  at  the  sides  of  the  pelvis — namely,  the  pelvic 
application.  My  object  in  the  use  of  the  forceps  in  these  cases  is  to  change 
a  high  occipito-posterior  position  into  a  medium  or  low  one,  then  to  remove 
the  forceps,  which  has  perhaps  grasped  the  head  obliquely,  adapt  it  over  the 
fetal  ears,  use  the  instrument  as  a  rotator,  and  instrumentally  rotate  the 
vertex  to  the  front  as  in  medium  and  low  cases.  (See  Operations,  Part  X.) 
(4)  Version:  Manual  anterior  rotation  or  forceps  without  manual  rotation  failing 
and.  the  fetus  being  still  alive,  version  remains  as  the  only  alternative.  I 
place  version  last  because  I  believe  the  forceps  alone  or  combined  with  manual 
rotation  offers  the  best  prognosis  in  the  hands  of  the  experienced  operator. 
If  by  reason  of  uterine  retraction  version  is  forbidden,  perforation  and  possibly 
symphyseotomy  should  be  considered. 

2.  Medium  Cases. — As  in  high  cases  of  persistent  occipito-posterior  posi- 
tions, the  first  step  in  the  treatment  is  to  insure  complete  flexion  of  the  head. 
Anterior  rotation  may  be  promoted  by  pressure  upon  the  forehead  applied 
during  a  pain.  This  pressure  should  be  applied  as  far  forward  as  possible. 
If  the  head  becomes  extended,  it  may  be  flexed  by  pushing  up  the  forehead 
or  pulling  down  the  occiput.  For  the  latter  purpose  a  vectis  or  blade  of  the 
forceps  may  be  used  if  there  is  no  room  for  the  hand.     If  the  expulsive  force  is  at 


550  PATHOLOGICAL   LABOR. 

fault,  the  judicious  use  of  remedies  for  delay  in  the  second  stage  may  be  employed 
(page  573).  If  all  efforts  at  rotation  fail  and  immediate  delivery  is  demanded, 
the  application  of  the  forceps  is  the  only  resource,  short  of  perforation.  (For 
the  use  of  the  forceps  in  occiput  posterior  positions  see  Operations,  Part  X.) 

3,  Low  Cases. — This  I  have  found  to  be  the  most  frequent  variety  of  occipito- 
posterior  cases  met  with.  The  forces  are  able  to  push  the  fetal  head  to  the 
pelvic  floor,  and  then  delayed  labor  ensues  by  reason  of  the  fact  that  the  forceps 
is  unable  either  to  rotate  the  occiput  anteriorly  or  to  deliver  the  head  of  the 
occiput  remaining  at  the  rear.  Whether  the  case  be  a  left  or  right  sacro-position, 
two  methods  of  delivery  in  the  case  of  a  living  fetus  are  open  to  us.  These 
are  (i)  forceps  delivery  with  the  occiput  still  posterior;  and  (2)  rotation  of  the 
occiput  anteriorly  with  the  forceps  and  delivery  as  in  anterior  positions  of  the 
vertex.  In  all  cases  with  the  exception  of  a  few  multiparas  with  lacerated  and 
relaxed  pelvic  floors  in  which  little  resistance  to  delivery  is  offered  1  would 
advise  the  second  plan  of  procedure, — namely,  anterior  rotation  of  the  occiput 
with  the  forceps, — for  the  reasons  that  less  laceration  of  the  pelvic  floor  occurs, 
and  the  fetal  morbidity  and  mortality  are  less  in  mechanical  anterior  rotation 
and  delivery.  Much  bitter  opposition  to  instrumental  rotation  of  the  present- 
ing part  has  been  expressed  by  English  and  American  obstetric  writers,  notably 
Playfair,*  Lusk,t  Hirst, f  and  Reynolds^;  the  French  and  German  writers 
taking  a  more  liberal  view  of  the  question.  Since  the  early  nineties  I  have 
been  teaching  and  using  instrumental  rotation  in  these  cases  in  both  hospital 
and  private  work,  and,  with  certain  limitations,  have  never  had  occasion  to 
regret  it.  A  paper  by  Brodhead,  ||  of  New  York,  read  before  the  New  York 
Obstetrical  Society,  brought  out  in  the  discussion  that  the  method,  in  New  York 
at  least,  was  coming  into  general  favor;  Cragin,  Tucker,  Marx,  Von  Ramdohr, 
and  I  indorsing  the  operation.     (See  Operations,  Part  X.) 

XIII.  PERSISTENT  MENTO-POSTERIOR  POSITION. 

Definition. — A  face  presentation  in  which  backward  rotation  of  the  chin 
occurs  in  the  first  and  second  positions,  or  in  which  a  persistent  mento-posterior 
position  obtains  in  the  third  and  fourth  positions  (Fig.  756). 

Frequency. — Face  positions  in  the  pelvic  cavity  with  the  chin  persistently 
behind  are  rare ;  their  existence  has  even  been  denied.  They  make  up  less  than 
one  per  cent,  of  all  face  positions. 

Etiology. — ( I )  The  face  may  engage  at  the  inlet  with  the  chin  behind  and  an- 
terior rotation  may  not  take  place;  (2)  or,  with  the  chin  in  front,  posterior  rota- 
tion occurs.  In  the  first  case  the  failure  of  anterior  rotation  is  due  to  the  relative 
disproportion  between  the  depth  of  the  excavation  at  the  side  and  the  length  of 
the  fetal  neck,  so  that  the  chin  does  not  meet  with  sufficient  resistance  to  produce 
anterior  rotation.  Certain  pelvic  deformities  or  obstructive  conditions  of  the  soft 
parts  might  produce  the  same  results.  The  prominence  of  the  bregmatic  region 
in  consideration  of  the  distance  it  must  travel  in  rotation  renders  necessary  the 
presence  of  strong,  persistent  uterine  contractions  and  capacity  of  the  head  for 
moulding.  The  second  variety  can  occur  only  with  a  very  large  pelvis  or  small 
head;  the  head  is  imperfectly  extended,  the  sinciput  meets  with  the  pelvic-floor 
resistance  before  the  chin  and  is  turned  forward,  carrying  the  chin  backward.     In 

*  "  Science  and  Practice  of  Midwifery,"  1S98. 

t  "The  Science  and  Art  of  Midwifery,"  1S92. 

J  "  Text-book  of  Obstetrics,"  i8q8.  §  "  Practice  of  Midwifery,"  1896. 

II  "American  Journal  of  Obstetrics,"  vol.  xlii,  No.  6,  1900. 


FETAL   DYSTOCIA   FROM   FAULTY   POSITION. 


551 


the  case  of  a  very  small  fetal  head  or  justo-major  pelvis  the  face  may  be  forced 
into  the  pelvis  with  extension  incomplete.  The  sinciput  strikes  the  pelvic  floor 
in  advance  of  the  chin.  If  the  chin  is  behind  in  the  inlet,  it  remains  behind;  if 
in  front,  the  sinciput  strikes  the  sacral  segment  of  the  pelvic  floor  and  rotates  for- 
ward, carrying  the  chin  backward. 

Mechanism. — To  understand  these  unreduced  mento-posterior  positions  we 
must  bear  in  mind  the  mechanism  of  normal  posterior  face  positions.  These 
presuppose  the  existence  of  complete  head  extension  by  virtue  of  which  the  chin 
is  first  to  strike  the  pelvic  floor  and  be  rotated  beneath  the  pubis.  When 
the  etiological  elements  already  enumerated  come  into  play  so  that  the  chin 
finds  its  way  to  the  hollow  of  the  sacrum,  the  head,  neck,  and  thorax  constitute 
a  wedge  which  with  further  progress  of  labor 
becomes  impacted.  The  almost  unanimous 
testimony  of  obstetricians  is  that  birth  of 
living  mature  children  in  mento-posterior 
positions  is  necessarily  impossible.  Ahlfeld 
states  that  a  few  cases  of  undoubted  authen- 
ticity are  on  record,  but  does  not  state  how 
such  births  were  made  possible.  The 
mechanism  of  this  position  in  relation  to 
its  essential  fatality  may  be  summarized  as 
follows :  Spontaneous  expulsion  is  impossible 
without  partial  or  complete  rotation  of  the 
chin  forward;  the  length  of  the  fetal  neck 
from  the  trunk  to  the  chin  is  about  2  inches 
(5.08  cm.) ;  the  posterior  wall  of  the  partur- 
ient canal  from  the  promontory  to  the  edge 
of  the  perineum  is  10  inches  (25.4  cm.);  the 
chin  cannot  reach  the  perineum  without  en- 
trance of  the  thorax  into  the  pelvis;  impac- 
tion results  because  the  trachelo-bregmatic 
diameter  of  the  head,  and  dorso-sternal  di- 
ameter of  the  thorax,  each  of  which  measures 
3^  inches  (8.89  cm.),  or  7  inches  (17.78  cm.) 
in  all,  attempt  to  pass  into  the  pelvis  at 
once.  Naturally  all  the  phenomena  of  ob- 
structed labor  result,  including  tetanoid  con- 
tractions of  the  uterus.  The  fetus  perishes 
from  asphyxia  as  a  consequence  of  compres- 
sion of  its  head  and  chest.    These  unreduced 

mento-posterior  positions  are  often  compared  with  those  in  which  the  occiput 
does  not  undergo  anterior  rotation.  In  the  occipito-posterior  variety  the  occiput 
clears  the  perineum  and  frees  the  head ;  but  in  the  mento-posterior  the  large  fon- 
tanelle  is  pressed  against  the  pubis,  and  for  the  chin  to  clear  the  perineum  a 
degree  of  extension  would  be  required  which  is  impossible  for  a  living,  full-sized 
fetus  (Fig.  756). 

Diagnosis. — In  a  mento-posterior  position  the  occiput  is  found  more  toward 
the  front  in  the  anterior  and  lower  part  of  the  uterus,  palpable  and  visible  from 
the  outside.  Internally  the  vaginal  vault  appears  flat  and  the  chin  stands  high 
and  is  difficult  to  reach  posteriorly.  The  fetal  cardiac  sounds  are  heard  with 
difficulty.     With  the  entire  hand  in  the  vagina  the  diagnosis  is  not  difficult. 

Prognosis. — This   position  is   universally   recognized   as   forming   the   most 


Fig.  754. — Moulding  of  the  Head  in 
Face  Presentation.  Primipara; 
R.  M.  P.;  first  stage  of  labor  three 
days;  membranes  ruptured  two 
days;  uterine  inertia;  manual  dila- 
tation of  cervix;  adaptation  of 
forceps.  Fronto-mental  diameter 
transverse  in  the  pelvis;  rotation 
with  the  forceps;  delivery  of  a  living 
child. — {Author's  case  at  Emergency 
Hospital.  December  8,  igo2.  From 
a  tracing.) 


552 


PATHOLOGICAL   LABOR. 


Fig.  755. — Moulding  from  Persistent  Mento-poste- 
RiOR  Position.  R.  M  P.;  prolonged  labor;  secondary 
inertia;  strychnia;  spontaneous  delivery  with  anterior 
rotation  of  the  chin. — {Author's  case  at  the  Emergency 
Hospital,  April,  1902.) 


serious  mechanical  complication  of  labor  arising  from  the  fetus.  The  child  mor- 
tality is  about  50  per  cent.  C.  B.  Reed*  collected  75  of  these  cases  from 
literature  and  found  the  maternal  mortality  11.6  per  cent,  or  about  the  maternal 
mortality  of  placenta  previa.  The  fetal  mortality  in  the  75  collected  cases  was 
40.6  per  cent.     This  series  includes  both  persistent  cases  at  the  inlet  and  outlet 

and  several  small  children. 
Persistent  cases  with  the 
chin  embedded  in  the  pelvic 
floor  with  a  full-sized  child 
give  a  fetal  mortality  of 
practically  100  per  cent. 
The  mother  is  exposed  to 
great  danger  and  the  mor- 
tality is  high. 

Treatment. — i.  At  the 
Pelvic  Inlet. — We  must  re- 
member that  less  than  i  per 
cent,  of  all  face  presenta- 
tions are  persistent  mento- 
posterior, hence  the  value 
of  expectancy  within  safe 
limits.  Defective  extension 
should  be  corrected  by  the 
fingers  or  hand.  Failure  of  engagement  of  the  face  at  the  inlet  calls  for  conver- 
sion into  a  vertex  by  Baudelocque's,  Thom's,  or  Schatz-Thom's  methods,  fol- 
lowed by  high  forceps  or  spontaneous  labor  in  posterior  chin  positions,  and 
podalic  version  and  extraction  in  anterior  chin  positions,  or  conversion  and  high 
forceps  in  both.  In  multiparae  I  prefer  podalic  version  and  extraction  to  the 
exclusion  of  other  com- 
bined methods. 

2.  In  the  Pelvic  Cav-  ~" 

ity. — Application  of  the 
hand  or  forceps  blade 
beneath  the  chin  will 
give  the  latter  a  point  of 
support  which  will  favor 
anterior  rotation.  Trac- 
tion with  forceps  will 
bring  the  chin  upon  the 
pelvic  floor  and  slight 
rotation  will  enable  it  to 
rotate  forward.  No  at- 
tempt should  ever  be 
made  to  deliver  the 
'chin  over  the  perineum. 
When  the  face  is  im- 
pacted,   the    indication 

must  lie  between  forceps  for  rotation,  symphyseotomy,  Cassarean  section,  and  em- 
bryotomy. The  original  teaching  of  Scanzoni  and  others  that  forceps  might  be 
used  to  turn  the  chin  forward  is  now  almost  universally  condemned.     Popescule  f 

*"  Amer.  Jour.  Obstet.,"  vol.  li.  No.  5,  1905. 
t  "  Centralbl.  f.  Gynakol.,"  Aug.  4,  1900. 


Fig.   756. — -Persistent  Mento-Posterior  Position. 


FETAL  DYSTOCIA   FROM   FAULTY  POSITION. 


553 


followed  this  advice  and  lost  the  mother.  He  states  that  he  would  never  use  the 
forceps  in  another  case.  Von  Braun  states  that  the  use  of  the  forceps  for  this 
complication  means  death  for  mother  and  child.  Doderlein  appears  to  think  that 
great  technical  skill  might  accomplish  something  with  the  forceps.  I  have  re- 
peatedly used  the  forceps  successfully  as  rotators  of  the  chin  anteriorly  when  the 
chin  had  not  become  embedded  in  the  pelvic  fioor,  and  when  it  did  not  point 
directly  posteriorly.  Popescule  first  brought  the  face  into  the  transverse  posi- 
tion. He  then  detached  the  blades,  reapplied  them,  turned  the  chin  under  the 
symphysis,  and  extracted  the  child.  In  the  past  most  authorities  agreed  that 
perforation  is  the  indication  of  necessity,  even  in  the  living  child.  Symphyseo- 
tomy has  been  suggested  as  applicable  to  this  complication.  It  has  been  once 
performed.* 


XIV.  TRANSVERSE  POSITION  OF  THE  HEAD  AT  THE  PELVIC 

OUTLET. 

Definition  and  Etiology. — Descent  of  the  head  occurs  without  anterior  rotation 
in  consequence  of  certain  anomalies  of  the  pelvis  or  fetus.  This  is  the  "deep 
transverse  position"  of  the  head.  This  position  is  primary  or  secondary.  The 
primary  position  is  found  in 
the  simple  fiat  pelvis,  in  the 
generally  contracted  fiat  pel- 
vis, and  in  the  masculine  or 
funnel-shaped  pelvis,  and 
even  in  the  larger  pelves 
when  the  head  is  very  small 
and  the  liquor  amnii  sud- 
denly lost  with  precipitate 
descent  of  the  head.  It  is 
also  found  in  congenital 
double  hip  dislocation.  In 
the  simple  flat  pelvis  the 
bregma  is  lower,  while  in  the 
generally  contracted  flat  pel- 
vis the  posterior  fontanelle  is 
lower.     Nearly  all  of  these 

cases  when  analyzed  show  themselves  to  be  occipito-anterior  presentations.  The 
secondary  position  is  found  when  the  head  is  large  and  the  occiput  is  broad,  as  in 
dolichocephalus.  The  occiput  continues  posterior  from  the  first  till  the  head 
reaches  the  floor  of  the  pelvis.  At  this  point  there  may  occur  a  partial  rotation  of 
the  occiput  into  the  transverse  diameter  of  the  outlet.  The  bregma  is  generally 
lower  than  the  occiput.  Incomplete  head  flexion  is  a  common  cause.  Again,  this 
position  may  occur  in  case  of  a  flat  pelvis  which  is  large  enough  to  let  the  head  pass 
the  inlet  in  an  oblique  diameter,  the  occiput  being  posterior,  but  which  is  so  con- 
tracted below  that  anterior  rotation  cannot  completely  take  place  as  in  the  mas- 
culine pelvis.  Reed  found  32  deep  transverse  arrests  of  the  head  in  3600  labors 
at  the  Chicago  Lying-in  Hospital,  or  0.9  per  cent.;  18  cases  occurred  in  multi- 
paras and  14  in  primiparse  (Fig.  757). 

Symptoms. — If  the  head  remains  in  this  position,  pressure  necrosis,  fistula, 
and  death  of  the  fetus  and  mother  may  occur.     The  head  may  be  bom  trans- 
versely, causing  extensive  laceration,  or  anterior  or  posterior  rotation  may  take 
*  Montgomery:  "Trans.  111.  Med.  Soc,"  1904. 


Fig.  757. — Transverse  Position  of  the  Head  at  thb 
Pelvic  Outlet,  Deep  Transverse  Position  of  thb 
Head. 


554  PATHOLOGICAL  LABOR. 

place.  In  some  cases  the  pains  may  entirely  cease  owing  to  the  obstruction  to 
labor.  In  others,  the  head  may  be  forced  through  the  bony  outlet  by  the  excessive 
strength  of  the  pains,  and  the  perineal  tissue  then  suffers.  Spontaneous  trans- 
verse delivery  may  rarely  occur  in  the  case  of  a  large  pelvis,  a  small  head,  and 
an  old  perineal  laceration.  Cases  are  known  in  which  the  head  if  it  continues  in 
extreme  flexion  is  bom  transversely  in  a  fiat  and  contracted  pelvis. 

Prognosis. — For  the  mother,  delayed  labor,  exhaustion,  and  sepsis;  for 
the  fetus,  asphyxia  or  death  from  compression  of  the  brain  or  placenta. 

Treatment. — Postural  treatment  offers  very  little.  Anterior  rotation  may 
be  favored  by  the  lateral  decubitus,  the  patient  lying  on  the  side  toward  which 
the  occiput  faces.  (See  Posture  in  Obstetrics,  Part  X.)  Stimulants,  such  as 
strychnin,  quinin,  and  alcohol,  may  be  administered  to  increase  the  expulsive 
forces.  Digital  rotation  with  the  hope  of  bringing  the  occiput  forward  may  be 
tried,  but  will  hardly  succeed  in  contracted  pelves:  (i)  With  two  fingers  in  the 
vagina  we  may  attempt  to  push  the  sinciput  posteriorly;  (2)  with  two  fingers 
or  the  whole  hand  in  the  vagina  we  may  lift  up  the  head  slightly  and  with  two 
fingers  of  the  other  hand  in  the  rectum  attempt  to  push  the  brow  backward; 
(3)  with  the  whole  hand  in  the  vagina  grasping  the  vault  of  the  head,  we  may 
attempt  both  to  raise  the  head  from  between  the  tubera  ischii  and  at  the  same 
time  rotate  the  occiput  anteriorly.  Failing  with  manual  correction,  the  forceps 
may  be  applied  over  the  parietal  bones;  and  failing  in  this,  in  an  oblique  pelvic 
diameter  and  rotation  combined  with  traction  used.  Symphyseotomy  has  its 
place  in  firm  impaction  and  a  living  fetus.  In  all  cases  of  impaction  with  a 
dead  fetus  the  head  should  be  perforated. 


FETAL   DYSTOCIA  FROM  GENERAL   FETAL  CONDITIONS. 

XV.     MULTIPLE  BIRTH. 

Definition. — The  birth  of  two,  three,  or  more  normal  fetuses.  Monsters 
are  not  included  under  this  head. 

Frequency. — The  proportion  of  multiple  to  single  births  varies  considerably 
in  different  countries.  The  ratio  of  triple,  twin,  and  ordinary  labors  in  Ger- 
many is  given  by  Strassmann  as  i  :  89  :  7921.  It  is  of  interest  to  note  that  in 
this  series  the  number  of  twin  pregnancies  is  exactly  the  square  root  of  the 
number  of  single  births.     For  the  etiology  see  page  140. 

Symptoms. — The  course  of  multiple  delivery  is  often  short.  After  one 
fetus  is  expelled  the  uterus  is  quiescent  for  a  certain  period;  upon  an  average, 
for  half  an  hour.  Instead  of  this  physiological  repose,  however,  prolonged 
inertia  may  develop.  In  such  cases  the  second  child  may  be  in  a  transverse 
position,  and  in  any  case  the  second  membranous  sac  should  be  ruptured  at 
the  expiration  of  half  an  hour.  The  cervix  being  fully  dilated  and  the  cord 
of  the  first  fetus  still  connected  with  the  placenta,  the  chances  for  intrauterine 
infection  are  considerable.  The  fetal  presentations  run  as  follows  in  twin  labors : 
the  commonest  form  is  the  double  vertex  (Fig.  762);  next,  the  fetus  to  be 
bom  first  presents  by  the  head,  the  other  by  the  breech  (Fig.  764);  third,  the 
first  fetus  presents  by  the  breech,  the  second  by  the  head;  fourth,  a  head  and  a 
shoulder  presentation  are  associated,  the  first  child  usually  presenting  by  the  head. 
Two  shoulder  presentations  occur  infrequently  (Fig.  761),  while  two  pelvic  pre- 
sentations are  very  exceptional.  Averaging  a  large  number  of  presenting  parts  in 
multiple  births  it  is  found  that  about  54  per  cent,  are  cephalic,  about  32  per  cent. 


Figs  758  to  764. — Presentations 
IN  Twin  Deliveries.  —  {After 
Dickinson.) 


Fig.  764. 


5.55 


556  PATHOLOGICAL  LABOR. 

pelvic,  while  the  remainder  are  shoulder.  About  three-fifths  of  the  heads  are  in 
the  first,  the  remainder  in  the  second  cranial  positions.  It  very  seldom  occurs 
that  both  heads  are  in  the  same  positions.  As  a  rule,  the  fetuses  are  face  to  face, 
and  the  one  on  the  left  side  is  bom  first,  the  right  coming  after  in  the  second 
cranial  position.  If  the  fetuses  are  placed  one  behind  the  other,  the  heads 
should  be  in  the  same  position.  In  regard  to  abnormal  presentation  in  twin 
pregnancy,  bregma,  brow,  and  face  positions  occur  more  frequently  than  with 
single  births,  comprising  not  less  than  lo  per  cent,  of  cephalic  births.  Bregma 
presentation  is  probably  increased  because  of  the  diminished  prominence  of  the 
frontal  region  in  twins,  which  reduces  the  resistance  encountered  at  the  pelvic 
inlet.  As  a  rule,  brow  and  face  presentations  run  a  more  favorable  course  than 
in  single  labors.     (For  diagnosis  and  prognosis  see  page  143.) 

Management  of  Twin  Labors. — In  the  case  of  abortion  of  one  twin  it  was 
once  the  practice  to  attempt  retention  of  the  second,  and  successes  have  been 
reported.  To-day  it  is  the  uniform  practice  to  bring  away  the  sound  fetus 
with  its  dead  fellow,  for  the  chance  of  saving  life  does  not  compensate  for  the 
danger  of  infection.  In  women  with  contracted  pelves  the  occurrence  of  multiple 
pregnancy  is  in  some  respects  an  actual  advantage.  It  occasionally  happens 
that  such  a  woman,  after  losing  a  series  of  normal  single  children  through 
dystocia  due  to  contracted  pelvis,  has  given  birth  to  living  twins  (I  have  my- 
self had  such  a  case),  and  even  in  cases  in  which  the  latter  were  both  in  shoulder 
presentation  (Strassmann).  For  this  reason  it  is  highly  important,  before 
inducing  premature  delivery  for  contracted  pelvis,  to  obtain  the  assurance 
of  the  non-existence  of  twin  pregnancy.  Symphyseotomy  must  never  be 
performed  unless  assurance  of  a  single  pregnancy  exists.  If  the  diagnosis 
of  twins  has  been  made  at  any  period,  the  woman  should  never  be  informed 
of  the  fact;  she  should  be  told  the  truth  only  after  the  first  birth.  The  leading 
indications  for  intervention  in  twin  labors  vary  with  the  two  children.  The 
presence  of  inertia,  so  common  in  these  births,  renders  it  necessary  at  times 
to  hasten  the  delivery  of  the  first  twin  by  artificial  measures.  With  its  fellow 
it  may  be  necessary  to  hasten  birth  by  reason  of  hemorrhage  or  failure  of  the 
fetal  heart.  The  necessity  for  narcosis  which  often  arises  during  extraction 
of  the  first  child  adds  to  the  likelihood  of  such  indications.  As  the  great  ma- 
jority of  twin  births  terminate  spontaneously,  non-intervention  should  be  the 
rule,  especially  in  vertex  presentations.  If  the  inertia  is  unduly  prolonged, 
the  membranes  should  be  ruptured  at  a  period  somewhat  earlier  than  in  single 
births.  The  first  step  after  the  first  child  has  been  delivered  and  the  cord 
ligated  is  to  make  a  vaginal  and  abdominal  examination.  If  the  second  fetus 
be  found  in  any  but  a  shoulder  presentation,  there  should  be  no  immediate 
intervention  save  for  causes  to  be  described  later,  since  in  most  cases  delivery 
is  easy  owing  to  the  dilatation  of  the  birth  canal  by  the  first  child,  and  because, 
owing  to  the  danger  of  post-partum  hemorrhage,  the  rapid  emptying  of  the 
uterus  is  inadvisable.  The  uterus  should  be  followed  down  by  the  hand  during 
the  stage  of  expulsion,  and  every  precaution  should  be  taken  against  the  occur- 
rence of  hemorrhage.  If  the  second  fetus  is  found  in  a  shoulder  presentation, 
cephalic  or  podalic  version  should  be  performed  and  extraction  effected  imme- 
diately unless  the  version  can  be  accomplished  by  the  external  or  combined 
methods  alone.  Post-partum  hemorrhage  after  the  first  labor  is  a  complication 
to  be  reckoned  with.  It  must  be  remembered  that  tears  of  the  cervix,  vagina, 
and  perineum  are  very  rare  in  twin  labors,  and  that  the  appearance  of  hemor- 
rhage after  the  first  birth  points  almost  certainly  to  a  placental  origin.  If 
the  placenta  is  single,  the  escaping  blood  is  a  menace  to  the  child  coming  after; 


FETAL  DYSTOCIA  FROM  GENERAL  FETAL  CONDITIONS.       557 

if  double,  the  second  child  is  not  compromised.  In  any  case  of  uncertain 
diagnosis  the  second  fetus  must  be  given  the  benefit  of  the  doubt  and  delivered 
at  once.  Failure  of  the  fetal  heart  is  an  indication  for  intervention.  In  the 
case  of  hemorrhage  or  other  source  of  danger  to  the  mother  or  the  second  infant, 
the  latter  should  be  rapidly  delivered  by  forceps  or  complete  version.  If 
after  an  hour  or  thereabouts  from  the  birth  of  the  first  child  the  uterus  does 
not  contract,  the  condition  of  atony  usually  demands  intervention.  Some 
authorities  see  no  harm  in  waiting  as  long  as  three  hours  if  the  condition  of 
the  mother  and  fetus  is  favorable.  Many  cases  are  on  record  in  which  the  second 
fetus  has  remained  in  utero  for  several  weeks  and  been  delivered  in  a  vigorous 
condition.  Hence,  if  the  first  child  is  premature  and  is  followed  by  its  placenta, 
it  may  be  wise  to  leave  the  second  child  in  utero,  that  its  chance  of  ultimate 
survival  may  be  improved.  When  it  is  decided  to  interfere,  the  membranes 
should  be  ruptured  and  massage  of  the  fundus  begun.  As  a  rule,  all  the  secun- 
dines  are  expelled  at  once  after  the  birth  of  the  second  child.  Owing  to  its 
large  size,  it  is  often  difficult  to  bring  away  the  placenta  by  Credo's  method. 
There  is  after  twin  labors  a  marked  tendency  to  atony  of  the  uterus  which 
demands  an  extra  large  dose  of  ergot  and  prolongation  of  the  usual  interval 
of  medical  supervision.  The  likelihood  of  hemorrhage  is  naturally  increased 
if  the  twins  are  expelled  in  quick  succession,  as  this  amounts  to  precipitate 
labor.  In  rare  cases  both  placentse  are  expelled  before  the  birth  of  the  second 
child,  which  must  then  be  delivered  at  once  to  avoid  suffocation.  In  the  case 
of  unioval  twins  (with  but  one  placenta)  a  twisting  and  entanglement  of  the 
cords  sufficient  to  retard  delivery  may  occur.  In  this  case  it  is  well  to  cut 
the  cord  between  two  ligatures  and  deliver  at  once;  or  the  division  of  both 
cords  may  be  required.  In  rare  cases  the  first  fetus  may  be  transverse  while 
the  second  is  astride  of  it  (Fig.  758).  This  possibility  should  be  remembered, 
since  in  such  a  case  traction  on  the  legs  of  the  second  would  be  disastrous. 

Management  of  Triple  Labor. — Labor  here  is  generally  easy  because  of  the 
small  size  of  the  fetuses.  As  in  twin  births,  dilatation  occurs  slowly  by  reason 
of  the  inertia  of  the  distended  uterus.  When  expulsion  begins,  however, 
the  labor  may  be  precipitate,  each  fetus  being  small  and  the  last  two  requiring 
no  delay  for  dilatation.  Each  bag  of  waters  presents  and  ruptures  in  turn, 
but  the  placentas  and  cords  show  much  variation.  Each  placenta  may 
follow  its  fetus  as  in  single  births;  the  first  two  placentas  may  come  away 
after  the  second  child,  or  all  three  may  follow  the  third  fetus.  The  interval 
between  the  labors  varies  greatly.  In  a  precipitate  delivery  there  is  no  interval 
and  the  children  may  all  be  expelled  in  fifteen  or  twenty  minutes.  In  other 
cases  there  may  be  a  short  interval  between  the  births  of  the  first  and  second 
fetuses  and  a  much  longer  one  between  the  second  and  third,  or  this  may  be 
reversed.  Apparently  the  complete  uterine  repose  which  occurs  between 
labors  in  a  twin  pregnancy  is  less  common  in  triple  births,  but  may  extend 
over  hours  and  even  days.  The  principal  presentation  is  the  cephalic — about 
60  per  cent.  The  tendency  to  abnormal  presentations  is  usuall}'-  seen  in  the 
last  child.  The  prognosis  for  the  mother  is  less  favorable  than  in  single  births. 
Notwithstanding  what  has  been  said  of  precipitate  labors  and  short  intervals, 
there  are  many  protracted  confinements  which  with  the  frequency  of  abnormal 
presentations  contribute  to  the  morbidity.  Puerperal  complications  are  fre- 
quent. The  fetal  mortality  is  very  heavy,  no  less  than  31  per  cent,  being 
still-bom. 


558  PATHOLOGICAL   LABOR. 


XVI.  MULTIPLE  OR  COMPOUND  PRESENTATION. 

Owing  to  the  small  size  of  the  fetus  in  multiple  labors  the  element  of  dystocia, 
whether  maternal  or  fetal,  is  essentially  out  of  the  question  under  ordinary 
conditions.  Indeed,  multiple  pregnancy  is  an  actual  advantage  to  a  woman 
with  contracted  pelvis.  The  situation  is  very  different  when  the  two  children 
tend  to  engage  in  the  pelvis  at  the  same  time,  and  especially  when,  by  reason 
of  the  unusually  small  size  of  the  heads,  they  succeed  in  so  doing.  Two  types 
of  complication  thus  arise,  termed  respectively  (i)  multiple  presentation  and 

(2)  interlocking  of  fetal  heads.     These  will  be  described  separately. 

1.  Multiple  Presentation. — In  multiple  presentation  we  find  parts  from  both 
fetuses  at  the  pelvic  inlet,  and  while  engagement  of  both  presenting  parts 
may  be  possible,  labor  may  be  retarded  by  the  fact  that  neither  part  is  able 
to  pass  the  brim.  The  presenting  parts  may  be  two  heads,  head  and  breech, 
head  and  limbs,  or  all  the  lower  extremities  (Figs.  695,  696,  697,  762,  763,  764). 
Treatment:  In  the  case  of  two  heads  or  a  head  and  breech,  the  hand  introduced 
into  the  vagina  should  endeavor  to  push  one  of  the  presenting  parts,  preferably 
that  which  is  higher  up,  upward  and  out  of  the  way.  While  this  manipula- 
tion might  suffice,  some  authors  advocate  engagement  of  the  lower  head  with 
forceps  to  prevent  a  return  of  the  complication.  If  a  head  and  limb  present 
together,  the  latter  may  be  pushed  up  and  the  head  engaged  with  the  forceps. 
If  the  lower  extremities  descend  into  the  pelvis,  those  which  belong  to  the  second 
fetus  should  be  pushed  up  while  the  first  fetus  should  be  extracted  by  its  feet.  A 
complication  of  somewhat  similar  nature  occurs  when  both  bags  of  waters 
project  into  the  dilating  cervix  and  delay  labor.  It  is  necessary  to  wait 
until  the  os  is  fully  opened,  after  which  the  most  advanced  bag  should  be 
punctured.  The  question  of  multiple  presentation  has  a  medico-legal  aspect, 
for  the  subject  of  the  right  of  priority  of  birth  sometimes  arises.  One  fetus 
could  present  first  by  an  extremity,  for  example,  while  the  other  might  be 
bom  before  it. 

2.  Interlocking  of  Fetal  Heads. — Interlocking  of  the  fetal  heads  occurs  in 
several  ways,  (i)  When  the  heads  are  unusually  small,  a  double  cephalic  pres- 
entation may  result  in  the  engagement  of  both,  the  second  entering  the  pelvic 
cavity  closely  after  the  first,  and  becoming  impacted  against  the  neck  or  thorax 
of  the  first  child  (Fig.  699).  Treatment:  In  the  first  form  of  interlocking  the 
management  usually  advised  is  to  deliver  the  first  fetus  with  the  forceps  and 
then  to  extract  the  second.  If  the  locking  cannot  be  overcome,  it  may  be  necessary 
to  perforate  and  dismember  the  first  fetus,  as  otherwise  both  may  be  lost.  The 
second  child  has  the  advantage  over  the  first  in  that  its  cord  is  in  less  danger 
of  compression.  Some  authorities  appear  to  regard  the  prospect  of  unlocking 
these  heads  as  practically  hopeless,  and  proceed  at  once  to  perform  craniotomy 
on  the  first  fetus.  (2)  If  the  first  twin  has  presented  by  the  breech  and  has 
entered  the  pelvis  with  the  exception  of  the  head,  the  second  head  may  slip  past 
it  into  the  excavation.  If  the  fetuses  are  face  to  face,  which  is  the  usual  rela- 
tion, the  two  chins  may  become  locked  together;  if  back  to  back,  the  occiputs; 
and  if  the  back  of  one  is  to  the  face  of  the  other,  the  locking  occurs  between  the 
chin  and  occiput  (Fig.  698).  Treatment:  The  first  step  is  an  attempt  to  push 
the  head  of  the  second  fetus  up  out  of  the  pelvis.  Failing  in  this,  expectancy 
may  be  tried;  but  if  there  is  no  advance,  the  forceps  should  be  applied. 
If  delivery  is  still  impossible,  the  head  of  the  fetus  which  dies  first  (usually  the 
first  one)  should  be  perforated  and  extracted  in  an  attempt  to  save  its  fellow. 

(3)  A.  second  fetus  in  shoulder  presentation  may  engage  during  the  birth  of  the 


FETAL  DYSTOCIA-  FROM  GENERAL  FETAL  CONDITIONS.        559 

first  fetus,  so  that  the  latter  is  arrested  before  some  part  of  the  trunk  has  entered 
the  pelvis.  Treatment:  The  engaged  portion  of  the  second  fetus  must  be  re- 
placed and  traction  made  upon  the  other  by  the  forceps  or  hands,  according  to 
the  presenting  part.  If  the  first  fetus  is  dead,  it  should  be  decapitated  and 
an  attempt  made  to  extract  the  other  by  version. 

XVII.  EXCESSIVELY  LONG  CORD. 

The  cord  is  frequently  increased  in  length;  instances  being  recorded  in 
which  it  was  from  six  to  nine  feet  long.  A  long  cord  may  become  entangled 
in  knots  or  it  may  become  coiled  about  the  fetus  till  so  little  is  left  that  the 
symptoms  of  short  funis  are  produced,  causing  delay  in  delivery.  (Seepage  559.) 
It  predisposes  to  prolapse  of  the  funis.  When  the  cord  is  coiled  several  times 
about  the  fetus,  compression  is  liable  to  cause  serious  or  fatal  asphyxia. 

XVIII.  SHORT  CORD. 

Definition. — Measurements  of  many  thousands  of  umbilical  cords  show 
that  the  great  majority  have  a  length  of  from  17  to  24  inches  (43.18  to  60.96 
cm.).  An  absolutely  short  cord  is  one  which  is  too  short  to  permit  of  delivery 
of  the  fetus  before  the  separation  of  the  placenta  (Fig.  280).  At  the  moment 
of  expulsion  the  distance  between  the  fundus  uteri  and  the  vulva  is  about  8 
inches  (20.32  cm.).  The  cord  must  therefore  be  at  least  of  that  length 
to  permit  of  the  birth  of  a  child.  But  the  distance  between  the  umbilicus 
and  anus  of  the  latter  must  be  added  if  expulsion  is  to  occur  easily,  so  that  the 
minimum  normal  length  of  the  cord  should  be  one  foot  (30.48  cm.)  for  head 
presentations,  and  by  a  like  calculation  15  inches  (38.1  cm.)  in  breech  cases. 
An  absolutely  short  cord  must  therefore  be  less  than  15  inches  (38.1  cm.).  This 
calculation  was  made  by  Tamier  and  Leroy  in  1893,  who  state  that  the  ex- 
tensibility of  the  cord  makes  the  above  figures  slightly  too  small  (about  10  per 
cent.).  The  same  effect  of  shortening  may  be  produced  in  connection  with 
coiling  of  the  cord  about  the  neck  or  limbs.  This  is  termed  the  accidentally 
short  cord,  and  is  elsewhere  considered.     (Page  237.) 

Etiology. — The  naturally  short  cord  is  purely  an  anomaly  of  development. 
It  has  been  noted  in  successive  labors  in  the  same  woman.  In  a  portion  of 
the  cases  reported  the  amniotic  fluid  has  been  scanty. 

Symptoms  and  Diagnosis. — There  is  no  method  by  which  a  short  cord  re- 
veals itself  during  pregnancy,  for  even  if  the  position  of  the  child  were  affected, 
as  has  been  claimed,  no  distinction  could  be  made  between  natural  and  artifi- 
cial shortening.  During  labor,  symptoms,  while  pronounced,  are  equivocal. 
With  everything  favorable  for  timely  expulsion  of  the  child,  labor  does  not 
advance  properly.  The  traction  upon  the  cord  during  each  pain  is  followed  by 
a  recoil  of  the  presenting  part,  which  is  due  to  the  elasticity  of  the  funis. 
In  individual  cases  the  condition  has  been  recognized  by  a  combination  of 
rational  symptoms,  such  as  tugging  and  unusual  distress  at  the  placental  site. 
It  doubtless  happens  that  the  conditions  become  manifest  only  when  the 
placenta  gives  way  with  hemorrhage,  or  when  the  uterus  becomes  inverted. 
It  would  seem,  at  first  sight,  that  after  labor  was  well  advanced  the  in- 
troduction of  the  hand  might  lead  to  a  recognition  of  the  condition,  but 
practically  nothing  can  be  learned  in  this  way.  Little  distinction  is  made 
in  practice  between  a  naturally  and  an  artificially  short  cord.  Brickner 
gives  the  symptomatology  of  short  cord  as  follows*:  (i)  Recession  of  the  head 
*  "Am.  Journ.  Med.  Sciences,"  Nov.,  1899. 


560  PATHOLOGICAL   LABOR. 

between  pains;  (2)  arterial  hemorrhage  during  and  between  pains;  (3)  urina- 
tion between  pains  during  expulsive  stage;  (4)  pain  over  the  placental  site, 
worse  during  the  expulsive  period;  (5)  desire  to  sit  up  and  lean  forward; 
(6)  uterine  inertia. 

Prognosis. — The  mother  is  endangered  by  the  possibility  of  hemorrhage  and 
inversion  of  the  uterus.     A  considerable  proportion  of  infants  are  still-born. 

Treatment. — If  there  are  reasons  for  suspecting  the  presence  of  a  short 
cord,  the  membranes  should  be  ruptured,  manual  expression  begun,  and  the 
forceps  applied.  According  to  Budin,  attempts  to  uncoil  the  cord  or  to  perform 
podalic  version  are  strictly  contraindicated.  If  brevity  of  the  cord  is  not 
suggested  till  the  head  is  arrested  in  the  excavation,  there  are  no  resources 
beyond  the  same  combination  of  manual  expression  and  forceps.  The  cord 
may  rupture  under  traction,  and  in  that  case  labor  must  be  terminated  rapidly 
and  the  funicular  hemorrhage  checked.  After  extraction  of  the  head  a  coiling 
of  the  cord  about  the  neck  may  be  discovered.  It  is  then  better  to  cut  and 
ligate  the  cord  than  to  try  to  loosen  the  coils.  The  artificially  short  cord  must 
not  be  confounded  with  the  cord  simply  coiled  about  the  neck  or  limbs,  produc- 
ing no  dystocia.  Some  of  these  coils  may  be  detached  incidentally  during  in- 
ternal version. 

XIX.  RUPTURE  OF  THE  UMBILICAL  CORD. 

Rupture  of  the  umbilical  cord  is  an  accident  of  rare  occurrence.  This  acci- 
dent may  arise  from  shortness  of  the  cord,  which  may  be  congenital,  or  from 
the  cord  becoming  wound  about  the  fetus.  It  may  also  be  due  to  abnormal 
insertion  of  the  cord,  or  to  precipitate  labor.  The  child  usually  dies  from  shock 
or  asphyxiation,  or  rarely  from  hemorrhage;  since  the  ruptured  vessels  are  pro- 
tected by  the  retraction  of  their  tissues  and  by  the  covering  of  Wharton's  jelly. 
When  this  complication  takes  place  before  the  child's  birth,  either  immediate 
version  or  the  use  of  the  forceps  is  indicated. 


XX.  DECAPITATION  OF  THE  FETUS. 

This  complication  is  also  very  rare,  but  sometimes  occurs  when  too  much 
force  has  been  applied  to  the  after-coming  head,  either  in  a  normal  breech 
presentation  or  after  version.  The  forceps  or  the  craniotractor  must  be  used  to 
extract  the  fetal  head,  external  pressure  at  the  same  time  being  employed  to 
hold  the  latter  in  place.  Danger  of  maternal  laceration  from  bony  spicules 
should  be  carefully  avoided.     (See  Operations,  Part  X.) 

XXI.  AVULSION  OF  THE  FETAL  EXTREMITIES. 

This  can  take  place  only  when  the  fetus  is  premature  or  partially  macerated. 
After  its  occurrence  the  rest  of  the  body  should  at  once  be  extracted.  It  will 
be  well  to  follow  extraction  by  an  antiseptic  douche. 

XXII.    FETAL  MALFORMATIONS,  DEFORMITIES,  AND  ANOMALIES 
PRODUCING  DYSTOCIA. 

Double  Monsters. — The  malformations  which  give  rise  to  dystocia  are 
limited  practically  to  the  double  monsters.  Single  fetuses  with  malformations 
do  not,  as  a  rule,  produce  obstructed  labors.     Double  monsters  as  causes  of 


FETAL  DYSTOCIA  FROM  GENERAL  FETAL  CONDITIONS.       561 

dystocia  are  best  divided,  as  proposed  by  Veit,  into:  (i)  Those  with  slight  sep- 
aration; (2)  those  with  moderate,  and  (3)  monsters  having  a  great  degree  of 
separation. 

We  may  state  that  the  greater  the  separation  the  greater  the  HkeHhood  of 
dystocia  (Figs.  385  to  435).  The  general  principle  of  treatment  which  I  fol- 
low in  these  cases  is:  (i)  Determine  the  character  of  the  obstruction  by  pass- 
ing the  hand  into  the  uterus.  (2)  If  an  extraction  with  the  aid  of  decapitation 
and  possibly  eventration  seems  feasible  deliver  in  this  way.     (3)   If  a  prolonged 


Fig.  765. 


Fig.  766. 


Fig.  767. 


Fig.  768.  Fig.  769. 

Figs.  765  to  769. — Fetal  Deformities  Producing  Dystocia.  Fig.  765,  Congenital 
hydrocephalus.  Fig.  766,  Anencephalus,  Fig.  767,  Distention  of  bladder  and  ureters. 
Fig.  768,  Dicephalus  dibrachius.     Fig.  769,  Thoracopagus. 


mutilating  and  difficult  extraction  is  required,  it  is  better  to  at  once  perform 
Caesarean  section.  (4)  Should  the  Csesarean  section  be  undertaken  after  pro- 
longed attempts  at  delivery,  and  sepsis  is  suspected,  either  an  incomplete  or 
complete  hysterectomy  should  follow  the  Caesarean  section. 

Oversize  of  the  Fetus. — There  is  no  standard  of  oversize,  though  infants 
weighing  over  13  pounds  (about  6000  gm.)  at  birth  are  very  rarely  encountered. 
A  few  cases  of  giant  fetuses  weighing  20  pounds  (9000  gm.)  and  upward  have 
been  recorded.  Excess  of  weight,  however,  does  not  necessarily  involve  a 
dystocic  labor,  for  the  head  of  such  a  child  may  have  a  good  capacity  for 
36 


562  PATHOLOGICAL  LABOR. 

moulding.  A  representative  case  of  an  overdeveloped  fetus  causing  d5''stocia  is 
one  described  by  A.  Martin.*  The  child  weighed  over  i6  pounds  (7500  gm.), 
and  could  not  be  delivered  until  craniotomy  had  been  performed.  Dystocia 
from  overdeveloped  children  is  common.  Etiology:  Overdevelopment  has  but 
two  known  causes:  (i)  Heredity;  the  children  of  giants,  especially  the  male 
children  of  a  giant  father,  having  a  tendency  to  overdevelopment  even  in  utero. 
(2)  Prolongation  of  pregnancy.  Post-mature  fetuses  naturally  continue  to  in- 
crease in  size  until  the  deferred  labor  sets  in.  Symptoms  and  Diagnosis :  A 
very  large  child  in  utero  may  simulate  a  twin  pregnancy  or  other  conditions 
of  distention.  Careful  palpation  and  cephalometry  (page  180)  will  show  that 
there  is  but  a  single  large  child.  Gestation  with  a  very  large  fetus  is  accom- 
panied by  the  same  phenomena  as  is  multiple  pregnancy.  The  distention  is 
partly  accounted  for  in  the  first  case  by  the  increased  volume  of  the  placenta 
and  amniotic  fluid.  Labor  with  overlarge  fetus  is  naturally  slow  and  numer- 
ous accidents  may  arise.  During  dilatation  the  cervix  may  give  way  with  a 
prolonged  tear  involving  the  body  of  the  uterus.  There  is  a  similar  danger 
of  rupture  of  the  lower  part  of  the  birth  tract,  especially  the  perineum.  Diag- 
nosis must  be  made  between  a  normal  large  head  and  hydrocephalus,  short 
funis,  and  other  causes  of  dystocia.  Treatment:  If  labor  cannot  end  spontane- 
ously without  danger  to  mother  and  child,  the  indication  is  clear  to  apply  the 
forceps.  Version  is  not  to  be  attempted.  If  the  child  succumbs  during  expul- 
sion, embryotomy  should  be  performed. 

Oversize  of  the  Head. — A  perfectly  normal  fetus  may  have  an  abnormally 
large  head,  associated  often  with  a  tendency  to  premature  ossification,  with 
resulting  diminution  in  the  size  of  the  fontanelles.  These  heads  resist  mould- 
ing, and  this  fact,  in  addition  to  their  size,  renders  them  apt  to  produce 
dystocia.  Treatment:  The  indications  are  the  same  as  in  the  preceding  class ; 
viz.,  expectancy  at  first  followed  later  by  the  forceps  if  necessary,  or  perfor- 
ation in  the  case  of  death  of  the  child. 

Premature  Ossification  of  Fetal  Skull. — The  symptoms,  results,  and  treat- 
ment are  the  same  as  the  preceding. 

Congenital  Hydrocephalus. — Diagnosis:  Abdominal  palpation  may  dis- 
cover a  large,  hard,  round  tumor  situated  above  the  pubes,  while  the  cardiac 
sounds  will  proceed  from  a  point  above  the  umbilicus.  Naturally  the  abdo- 
men is  greatly  distended.  Failing  to  recognize  the  usual  evidences  of  a  head 
presentation,  the  practitioner  may  believe  that  a  breech  presentation  exists. 
Examination  with  the  entire  hand  is  necessary  for  diagnosis.  In  breech  pre- 
sentations the  presence  of  a  large  mass  in  the  uterus  during  expulsion  of  the 
trunk  might  lead  to  belief  in  the  presence  of  a  second  fetus,  uterine 
fibroid,  etc.  The  presence  of  spina  bifida  in  breech  cases  has  sometimes 
led  to  a  suspicion  of  hydrocephalus.  Prognosis:  The  outlook  is  grave. 
Very  few  labors  terminate  spontaneously.  In  cases  in  which  an  early  diag- 
nosis is  not  made  the  mortality  is  high.  When  the  complication  is  foreseen, 
the  outlook  for  the  mother  is  good.  For  the  mother  in  undetected  cases  the  out- 
look is  bad,  although  it  has  been  recently  improved  by  superior  antisepsis.  The 
mortality  to  the  mother  averages  about  2  5  per  cent.  (Poulet  and  Spiegelberg). 
Rupture  of  the  uterus  is  not  uncommon,  either  near  the  cervix  or  at  the 
fundus.  Vesico -vaginal  fistula  may  result  from  the  pressure  of  the  fetal  head. 
If  the  nature  of  the  complication  is  unsuspected,  matters  may  be  made  worse 
by  attempts  at  version  or  forceps  delivery.  Treatment:  The  prophylaxis 
of  hydrocephalus  hardly  exists,  despite  certain  efforts  in  this  direction.     If 

*  Cited  by  Tamier  and  Budin,  edition  1900,  Paris. 


FETAL  DYSTOCIA  FROM  GENERAL  FETAL  CONDITIONS.      563 

the  condition  is  recognized  during  the  latter  months  of  pregnancy,  the  fetus 
may  be  placed  in  a  pelvic  presentation,  as  there  is  less  danger  then  of  rupture 
of  the  uterus.  When  labor  is  much  delayed  by  this  complication,  puncture  of 
the  head  and  withdrawal  of  the  accumulated  fluid  are  demanded.  The  cranial 
bones  then  collapse.  If  the  aspirator  is  used,  it  will  withdraw  the  fluid 
effectually,  and  give  the  child  a  chance  of  life.  Even  a  short  period  of  extra- 
uterine existence  may  sometimes  be  of  great  medico-legal  importance.  After 
perforation,  turning  has  been  advised,  but  this  is  usually  superfluous,  for  the 
pains  are  generally  sufficient  to  complete  the  birth.  If  there  is  difficulty  in 
the  descent  of  the  head,  application  of  the  cephalotribe  is  in  order.  This  will 
crush  the  head,  so  that  it  will  be  readily  extracted.  The  forceps  should  not  be 
used,  for  the  blades  are  too  short,  and  the  cephalic  curve  is  not  large  enough. 
The  head,  too,  is  so  distended  that  its  form  changes  with  pressure  to  such  a 
degree  that  the  forceps  cannot  secure  a  firm  grasp.  It  is  only  when  the  head  is 
closely  and  deeply  wedged  in  the  pelvis,  and  its  capsule  is  unyielding,  that  any 
success  with  the  forceps  may  be  hoped  for.  In  breech  cases  the  skull  may  be 
perforated  from  beneath.  The  French  claim  that  the  simplest  manner  of 
withdrawing  the  fluid  is  by  puncturing  the  spine.  This  procedure,  adopted  by 
Tarnier  in  1868,  has  been  employed  by  all  of  his  pupils.  I  always  perforate 
through  the  floor  and  roof  of  the  mouth.  Cases  of  shoulder  presentation  should 
be  treated  by  preliminary  podalic  version  and  afterward  as  in  the  management  of 
breech  cases.      If  version  is  contraindicated,  decapitation  should  be  practised. 

Encephalocele;  Hydrencephalocele  (Figs.  329,  330). — This  condition  is  rarely 
a  cause  of  dystocia.  The  tumor  which  projects  from  the  skull  consists  only  of 
fluid  in  a  membranous  sac.  If  large  enough  to  obstruct  labor,  it  could  readily  be 
tapped.  Epignathi  (Fig.  430) :  These  parasitic  tumors,  growing  as  they  do  from 
the  mouth,  are  able,  if  they  are  large,  to  cause  more  or  less  dystocia.  They  are 
freely  movable  on  the  fetus  and  extraction  can  usually  be  effected  by  version.  If 
this  fails,  the  epignathus  must  be  reduced  in  size.  Anencephalus  (Fig.  367) :  In 
this  monstrosity  dystocia  arises  from  the  fact  that  the  rudimentary  skull  is  in- 
sufficient to  pave  the  way  for  the  shoulders.  The  condition  is  therefore  one  of 
shoulder  dystocia,  for  which  see  page  538.  Cystic  Hygroma:  These  cystic  for- 
mations grow  from  the  neck  or  the  front  of  the  chest,  and  may  equal  the  fetal 
head  in  size.  They  are  retention  cysts  which  arise  after  occlusion  of  the 
lymphatics.  Congenital  Cystic  Goitre:  This  may  be  classed  with  the  foregoing 
in  relation  to  dystocia.  Winckel  gives  considerable  attention  to  these  cysts 
of  the  neck,  as  do  also  Tarnier  and  Budin.  The  cysts  are  not  diagnosticated 
until  labor  has  begun,  and  then  are  made  out  only  with  several  fingers  in  the 
vagina,  and  sometimes  not  until  after  delivery.  If  moderate  traction  will  not 
bring  away  the  child,  the  tumor  should  be  punctured  with  a  curved  trocar. 
The  greatest  care  should  be  taken,  since  these  cysts  do  not  jeopardize  the 
child. 

Unusual  "Width  of  the  Shoulders  and  Chest. — The  shoulders  and  thorax  of 
a  very  large  child  do  not  appear  to  cause  d3^stocia.  Unusual  development 
of  these  parts  in  an  ordinary  child,  as  well  as  the  absolute  and  relative  width 
of  the  shoulders  in  pseudo-encephali  and  anencephali,  constitutes  the  state 
which  produces  dystocia.  Similar  in  dystocic  effect  is  congenital  hydrothorax. 
Labor  in  such  cases  might  be  arrested  with  the  shoulders  in  the  inlet,  and  the 
efforts  of  the  uterus  to  expel  the  child  might  asphyxiate  it  as  a  result  of  com- 
pression of  the  chest.  Diagnosis:  These  conditions  cannot  be  recognized 
till  after  the  birth  of  the  head  or  the  breech,  when,  with  the  entire  hand 
in  the  vagina,  the  diagnosis  may  be  made.      Treatment:     This  should  not  be 


564  PATHOLOGICAL   LABOR. 

confounded  with  the  management  of  deficient  rotation  of  the  shoulders.  To 
overcome  the  impaction  present  in  actual  dystocia  it  will  probably  be  neces- 
sary to  perform  cleidotomy.     (See  Operation,  Part  X.) 

Ascites. — (See  Trunk  Dystocia.)     (Fig.  767.) 

Tumors  which  Originate  in  the  Urinary  Apparatus. — These  comprise  ac- 
cumulations of  fluid  in  the  bladder  or  kidneys  due  to  imperforate  urethra 
or  some  other  malformation,  and  also  the  condition  known  as  congenital  cystic 
degeneration  of  the  kidney.  Both  distended  bladder  and  hydronephrosis 
may  attain  an  enormous  size  in  comparison  with  the  fetus  (Fig.  767).  While 
the  average  quantity  of  urine  which  thus  accumulates  is  not  over  a  pint, 
there  are  cases  upon  record  in  which  the  retention  amounted  to  seven  quarts. 
The  kidneys  in  cystic  degeneration  form  a  large,  solid  tumor  which  is  made 
up  of  innumerable  retention  cysts  developed  from  the  urinary  canaliculi. 
These  cysts  are  filled  with  urine,  and  when  the  process  is  extensive  a  large 
abdominal  tumor  results.  It  is  supposed  that  the  retention  is  due  originally 
to  a  sclerotic  process  in  the  renal  papillas.  An  analogous  affection  of  the  liver 
sometimes  coexists. 

Dystocia  Due  to  Affections  of  the  Fetal  Trunk. — Symptoms :  During  labor  in 
cephalic  presentations  after  the  head  is  born,  the  process  of  delivery  is  arrested. 
If  an  inexperienced  practitioner  attempts  to  extract  the  child  forcibly,  he  will 
be  likely  to  disrupt  it.  If  the  case  is  a  breech,  the  conditions  are  analogous. 
A  fetus  with  retention  of  urine  almost  always  presents  by  the  head.  Naturally 
there  is  a  scantiness  of  the  amniotic  fluid.  Diagnosis :  If  there  is  obstruction  due 
to  something  above  the  shoulders,  the  entire  hand  should  be  inserted  into  the 
birth  tract,  when  the  nature  of  the  obstacle  will  become  apparent.  An  attempt 
should  be  made  to  determine  whether  the  tumor  is  solid  or  fluid.  An  analogous 
course  should  be  pursued  in  breech  cases.  Prognosis:  The  outlook  is  naturally 
grave  for  the  fetus.  For  the  mother,  all  depends  upon  the  management  of  the 
case.  If  the  cause  of  dystocia  is  not  recognized  and  removed,  she  will  be  ex- 
posed to  extensive  rupture  of  the  genital  tract  by  the  futile  attempt  at  delivery. 
If  the  correct  diagnosis  is  made,  the  mother's  chances  are  vastly  improved. 
Treatment:  In  head  presentations  with  the  head  arrested  in  the  excavation, 
the  forceps  should  be  applied  to  deliver  it.  Any  coils  of  cord  about  the  fetal 
neck  should  be  unwound.  Traction  should  be  resumed  gently  until  no  further 
advance  is  possible,  after  which  the  hand  in  the  vagina  will  complete  the  diag- 
nosis as  to  the  nature  of  the  tumor.  If  the  latter  contains  fluid  and  the  infant 
is  dead,  the  abdomen  should  be  opened  by  a  perforator.  Labor  may  then 
be  readily  completed.  If  the  child  is  living,  puncture  should  be  made  at  the 
umbilicus  with  a  fine  trocar.  If  the  tumor  is  solid,  the  child  must  be  eviscer- 
ated whether  dead  or  alive.  In  breech  cases  an  analogous  course  must  be 
pursued.  It  must  be  remembered  that  the  placenta  is  very  large  in  some  cases 
of  ascites;  if  this  is  forgotten,  the  uterine  tumor  might  suggest  a  second  fetus. 

Sacro-coccygeal  Tumors. — (Figs.  432  and  770.)  They  are  seldom  recog- 
nized during  pregnancy.  Hydramnios  is  present  in  the  vast  majority  of 
cases.  Symptoms:  Labor  is  almost  always  premature.  The  head  usually 
presents.  Delivery  occurs  spontaneously  in  the  vast  majority  of  cases. 
This  implies  that  the  majority  of  tumors  are  too  small  to  affect  labor. 
More  or  less  dystocia  must  occur  with  growths  the  size  of  the  fetal  head. 
The  degree  of  dystocia  is  not  in  proportion  to  the  size  of  the  tumor,  for  the 
latter  may  be  partially  cystic,  and  hence  easily  reducible  in  size.  In  head 
presentations  with  a  large  solid  tumor  the  latter  will  probably  be  expelled  spon- 
taneously after  a  period  of  moulding.      In  pelvic  presentations  a  high  degree 


FETAL  DYSTOCIA  FROM  GENERAL  FETAL  CONDITIONS.       565 


of  dystocia  may  result,  the  trunk  and  tumor  seeking  to  engage  at  the  same 
time.  If  the  feet  are  down,  efforts  at  traction  might  disrupt  the  fetus.  Diag- 
nosis: This  can  be  made  only  with  the  entire  hand  in  the  vagina,  chloroform 
having  been  given.  A  tumor  of  this  sort  might  well  be  confounded  with  a 
number  of  conditions,  fetal  or  maternal.  Budin  states  that  the  commonest 
error  is  the  assumption  of  the  presence  of  a  double  monster  united  at  the  breech. 
Prognosis:  In  dystocia  the  maternal  prognosis  depends,  as  in  all  similar  con- 
ditions, upon  the  time  at  which  the  diagnosis  is  made.  The  outlook  for  the 
child  is  very  poor,  there  being  but  a  small 
proportion  of  survivors.  Treatment:  The 
dystocia  is  less  than  in  the  case  of  abdom- 
inal tumors.  In  head  presentations  traction 
should  be  made  with  forceps  until  it  becomes 
evident  that  delivery  is  impossible.  Punc- 
ture should  be  practised  in  several  places  in 
the  hope  that  the  tumor  is  partly  fluid.  If 
this  fail,  the  child  must  be  eventrated,  after 
which  the  legs  may  be  extracted  and  the 
tumor  treated  by  morcellation,  while  in  a 
breech  case  the  tumor  must  be  made  to  pre- 
sent first  with  the  same  intent. 


XXIII.    FETAL   RIGOR  MORTIS. 

Although  death  of  the  fetus  is  of  such 
common  occurrence,  rigor  mortis  has  been 
noted  so  rarely  that  the  possibility  of  such 
a  phenomenon  has  been  denied.  Ballantyne, 
who  has  seen  one  case,  gives  references  to 
about  twenty-five  others  in  literature,  several 
of  the  latter  having  been  described  in  connec- 
tion with  Caesarean  section.  Cadaveric  rigi- 
dity in  the  fetus  is  believed  to  be  feeble  and 
transitory,  and  to  escape  observation  unless 
death  occurs  just  before  labor  begins.  In 
some  cases,  however,  the  condition  is  well 
marked,  and  may  last  for  hours,  proving  a 
source  of  fetal  dystocia.  Wolff  *  analyzed 
34  recorded  cases  of  this  phenomenon.  The 
claim  which  has  often  been  made  that 
eclampsia    plays    a   prominent    part    in   its 

genesis  is  not  borne  out  by  statistics,  for  maternal  convulsions  occurred  in  but  8 
pf  these  34  cases.  This  coincidence  is  evidently  due  to  the  fact  that  the  fetus 
often  perishes  during  an  eclamptic  delivery.  For  similar  reasons  we  find  the 
coincidence  of  protracted  and  obstructed  labor,  prolapsed  cord,  placenta  praevia, 
premature  detached  placenta,  etc.,  on  one  hand,  and  antenatal  rigor  mortis  on 
the  other. 

Of  the  34  cases  detailed  by  Wolff,  no  less  than  30  were  associated  with  the 
conditions  just  enumerated. 

These,  however,  were  not  sufficient  in  themselves  to  determine  rigor  mortis 
in  the  fetus.     In  a  large  proportion  of  cases,  the  latter  may  be  brought  in  re- 

*  *' Arch.  f.  Gynakol.,"   lxviii,  IQ03. 


Fig.  770. — Sacro-coccygeal  Tumor 
IN  A  Female  Fetus  Born  at  the 
Sixth  Month. — (Author's  collec- 
tion.) 


566  PATHOLOGICAL   LABOR. 

lation  with  death  of  the  mother  during  labor,  and  it  is  not  uncommon  for  the 
rigid  state  of  the  fetus  to  be  recognized  in  connection  with  Caesarean  section  on 
the  dead  or  dying. 

On  June  12,  1904,  a  primipara,  age  30,  already  fourteen  hours  in  labor  was  admitted 
into  my  service  at  the  Bellevue  Emergency  Hospital.  Csesarean  section  was  required,  and 
performed  by  my  assistant,  Dr.  Moore.  Two  hours  before  the  operation  the  fetal  heart 
sounds  were  heard  by  several  observers.  A  dead  nine  pound  child  was  extracted  with  rigor 
mortis  present  to  a  marked  degree.  The  extremities  were  flexed  upon  the  body  and  were 
so  rigid  as  to  raake  it  practically  impossible  to  extend  them.  The  fetal  body  and  neck 
were  also  in  complete  rigor  mortis.  This  case  was  of  rapid  development,  as  the  fetal  heart 
sounds  had  been  heard  up  to  two  hours  of  operation.  The  patient  died  suddenly  eighteen 
hours  post-partum.     No  autopsy  could  be  obtained. 


DUE  TO  ABNORMAL  CONDITIONS  IN  THE  MOTHER: 
MATERNAL   DYSTOCIA. 

Physical  Phenomena  of  Maternal  Dystocia. — Much  confusion  exists  in  regard 
to  the  results  of  difficult  labor  upon  the  maternal  organism,  and  the  terms  "  prim- 
ary inertia,"  "uterine  exhaustion,"  "secondary  inertia,"  "tetanic  state  of  the 
uterus,"  "delayed  labor,"  "obstructed  labor,"  are  applied  somewhat  indis- 
criminately to  designate  various  phases  of  such  conditions.  An  attempt  is  made 
to  submit  these  conditions  to  a  brief  analysis. 

Primary  Inertia. — Here  the  sluggish  action  of  the  uterus  is  not  due  to  ex- 
haustion. The  causes  lie  in  the  uterine  muscle  itself,  which  is  unable  to  contract 
forcibly.  We  see  this  in  the  very  young  and  in  the  elderly;  in  invalids  and  in 
distention  of  the  uterus  by  hydramnios,  multiple  pregnancy,  etc.  The  pains 
are  weak  and  occur  at  long  intervals.  There  is  no  constitutional  reaction  beyond 
fatigue.     The  subject  of  inertia  is  considered  in  detail  under  Protracted  Labor. 

Secondary  Inertia,  Exhaustion  of  the  Uterus. — ^This  appears  to  be  the  result 
of  inertia  of  the  uterus  plus  slight  obstruction ;  although  the  latter  is  not  always 
in  evidence.  .  The  pains,  feeble  at  the  start,  ultimately  cease.  The  uterus  seeks 
rest.  This  temporary  suspension  of  the  pains  has  been  termed  secondary  inertia 
in  contradistinction  to  obstructed  labor  with  original  absence  of  inertia.  Exhaus- 
tion of  the  uterus  betrays  itself  by  flabbiness,  which  enables  the  obstetrician 
to  recognize  the  outlines  of  the  child.  There  is  no  tenderness  on  pressure. 
A-side  from  fatigue,  constitutional  reaction  is  absent.  After  rest,  food,  and  sleep 
the  uterine  contractions  reappear. 

Tetanic  State  of  the  Uterus. — This  anomalous  action  of  the  uterine  muscle 
develops  when  an  obstruction  is  present.  The  original  pains  become  vigorous 
when  the  obstruction  is  first  felt,  but  if  the  impediment  cannot  be  overcome,  the 
intervals  between  the  pains  become  shorter  and  shorter  until  the  tetanoid  state 
develops.  The  fetus  is  closely  embraced  by  the  uterus  and  the  constant  pressure 
tends  to  interfere  with  the  placental  circulation.  The  constitutional  reaction 
is  marked,  as  the  tetanic  contraction  rapidly  exhausts  the  mother.  Her  pulse 
and  respiration  increase  and  her  face  shows  anxiety.  The  uterus  is  hard  and 
perhaps  tender.  It  holds  the  fetus  firmly,  so  that  the  presenting  part  cannot 
be  pushed  up.  If  the  head  has  reached  the  true  pelvis,  it  shows  a  marked  caput 
succedaneum,  while  the  lower  part  of  the  birth  tract  is  swollen.  In  this  condi- 
tion immediate  delivery  is  the  indication. 

Prolonged  Labor. — Primary  inertia,  exhaustion,  and  obstruction  all  tend  to 
lengthen  the  duration  of  labor.     What  is  meant  by  prolonged  labor  in  the  nar- 


MATERNAL  DYSTOCIA   FROM   THE  FORCES.  567 

rower  sense  of  the  term  is  the  result  of  a  moderate  disproportion  between  the  force 
and  the  resistance.  Let  us  suppose  that  the  pains  are  strong  and  that  the  resist- 
ance does  not  amount  to  obstruction.  Tetanus  uteri  does  not  develop.  The 
woman  is  simply  in  the  position  of  one  who  makes  great  and  long-continued  mus- 
cular exertion,  and  the  results  are  those  which  follow  such  efforts.  The  pulse 
rises  to  loo  or  120  and  there  is  rise  of  temperature.  The  patient  becomes  anxious, 
distressed,  and  restless ;  vomiting  of  reflex  origin  may  occur ;  the  tongue  is  coated, 
the  vaginal  and  cervical  secretions  are  arrested,  and  the  parts  are  hot  and  dry. 
Such  a  clinical  picture  may  be  seen  in  breech  presentations. 

Obstructed  Labor. — Tetanic  contractions  indicate  that  there  is  an  obstruction 
to  labor.  There  is  only  a  difference  in  degree  between  a  protracted  labor  as  de- 
scribed and  an  obstructed  labor.  The  term  should  be  restricted  to  cases  in  which 
delivery  by  natural  passages  is  impossible.  At  the  outset  the  symptoms  are 
those  of  protracted  labor.  Finally  exhaustion  of  the  mother  begins ;  the  pulse 
becomes  weak  and  thready;  jactitation  indicates  the  high  degree  of  nervous 
prostration;  the  tongue  becomes  black  and  dry,  and  the  patient  passes  into  a 
typhoid  or  adynamic  state  as  a  result  of  the  profound  exhaustion. 


MATERNAL  DYSTOCIA  FROM  THE  FORCES. 

I.  PRECIPITATE  LABOR. 

Definition. — Labor  terminating  so  rapidly  as  to  interfere  with  the  physio- 
logical processes  of  the  several  stages.  Its  occurrence  is  comparatively  infre- 
quent. A  narrower  definition  is  labor  of  such  rapid  and  unforeseen  character 
that  the  parturient  is  confined  in  an  entirely  unusual  position,  as  standing, 
squatting,  kneeling,  or  sitting 

Etiology. — Excessive  expulsive  powers,  either  voluntary  or  involuntary,  and 
deficiency  in  the  resistance  in  the  parturient  canal  or  bony  pelvis  are  the  main 
etiological  features.  The  physical  condition  of  the  patient  seems  to  have 
little  or  nothing  to  do  with  the  excessive  contraction.  Deficiency  in  the  resist- 
ance may  result  from  a  number  of  causes.  For  example,  there  may  be  an  under- 
sized child  at  full  term  or  as  the  result  of  premature  labor.  The  parturient 
canal  itself  may  be  oversized  and  roomy  and  relaxed  as  the  result  of  the  general 
physical  condition  or  nervous  influences  independent  of  an  increase  in  the  size 
of  the  pelvis.  The  justo-major  or  giant  pelvis  and  the  split  or  inverted  pelvis 
are  the  two  conditions  in  the  hard  parts  predisposing  to  precipitate  labor.  It 
may  be  that  in  a  previous  confinement  there  have  been  lacerations  of  the  cervix 
or  perineum,  or  both,  allowing  the  fetus  to  be  precipitated  through  an  orifice, 
instead  of  being  forced  along,  as  is  normally  the  case. 

Symptoms. — The  symptoms  are  those  of  a  rapidly  terminating  labor.  The 
pains  appear  suddenly  and  increase  very  rapidly  in  intensity.  They  are  usually 
of  a  bearing-down  character  from  the  beginning.  Labor  may  be  over  in  a  few 
minutes  when  the  pelvis  is  large  or  the  fetus  small,  even  without  any  excruciating 
pains.  However,  the  converse  may  prove  true.  The  child  may  even  be  bom 
while  the  mother  is  asleep. 

Diagnosis.— One  or  two  contractions  sometimes  expel  the  fetus.  In  other 
cases  palpation  shows  a  rapidly  advancing  presenting  part,  almost  continuous 
tetanic  action  of  the  uterus,  and  forcible  contraction  of  the  abdominal  walls. 
The  latter  may  be  absent.     In  cases  in  which  there  are  only  one  or  two  severe  con- 


568  PATHOLOGICAL   LABOR. 

tractions  the  patient  is  probably  of  a  sluggish,  apathetic  temperament  and  does 
not  really  feel  much  pain.  In  other  cases  which  are  not  so  rapid  the  suffering  may 
be  intense.  If  the  child  dies  from  rupture  of  the  cord  as  a  result  of  precipitate 
labor,  the  mother  may  be  subjected  to  judicial  inquiry  by  reason  of  the  fact 
that  infanticide  is  sometimes  committed  through  neglect  to  ligate  the  cord. 
Similarly,  a  fall  of  the  child  in  connection  with  precipitate  labor  may  lead  to 
injtiries  of  the  cranium,  limbs,  viscera,  etc.,  and  hence  the  suspicion  of  attempt 
at  infanticide  may  be  aroused.  In  cases  of  this  sort  in  which  the  mother  is 
accused  but  denies  all  intent  of  injuring  the  child,  corroboration  of  her  word  may 
be  supplied  by  study  of  the  pelvis  and  soft  parts  and  of  the  fetus.  If  the  pelvis 
is  over-large  and  there  are  old  lacerations  which  have  diminished  the  resistance, 
etc.,  or  if  the  child  is  unusually  small,  we  have  conditions  which  favor  precipi- 
tate labor.  If  we  find  the  uterus  inverted,  extensive  fresh  lacerations  of  the 
soft  parts,  with  a  history  of  post-partum  hemorrhage,  etc.,  we  have  conditions 
which  may  have  been  caused  by  precipitate  labor.  In  regard  to  the  child  dead 
of  hemorrhage  from  the  cord,  it  will  be  necessary  to  exclude  the  existence  of 
patent  umbilical  arteries,  anomalies  of  the  cord  and  vessels,  and  hemophilia. 
Much  may  be  learned  from  cross-examination  of  the  mother. 

Prognosis. — The  dangers  to  the  mother  are  hemorrhage  from  premature  de- 
tachment of  the  placenta,  lacerations  of  the  parturient  tract,  post-partum  hem- 
orrhage, inversion  of  the  uterus,  serious  or  fatal  syncope  from  sudden  diminution 
of  intra-abdominal  pressure,  and  uterine  inertia.  The  dangers  to  the  fetus  are 
ante-partum  asphyxia  from  premature  detachment  or  compression  of  the  placenta 
or  from  rupture  of  the  cord,  and  injury  from  a  fall  to  the  floor,  to  the  street,  or 
into  the  basin  of  a  water-closet.  I  had  a  case  in  practice  of  a  child  being  born 
by  precipitate  labor  into  the  bowl  of  a  water-closet.  I  was  asked  once  to  see 
a  depression  in  a  parietal  bone  in  a  newly  born  infant,  the  restdt  of  precipitate 
labor  on  the  fire-escape  of  a  tenement-house.  The  mother  at  the  time  was 
leaning  over  the  railing  and  drawing  the  clothes-line  toward  her.  Both  these 
children  survived.  I  have  also  witnessed  a  precipitate  labor  in  a  patient  ascend- 
ing a  staircase  in  a  maternity  hospital,  the  child's  fall  in  this  case  being 
broken  by  being  suspended  by  the  cord.  No  complications  resulted  to  the 
mothers  in  these  three  cases. 

Treatment. — When  precipitate  labor  has  once  occurred,  it  is  likely  to  take 
place  again,  and  in  such  a  case,  preventive  treatment  is  in  order  during  preg- 
nancy. During  the  last  few  weeks  of  pregnancy  the  patient  should  not  go  far 
from  home  and  should  secure  fresh  air  by  driving  rather  than  walking.  A  com- 
petent nurse,  who  can  take  entire  charge  of  labor  if  necessary,  should  during  this 
time  be  in  attendance.  A  well-fitting  abdominal  binder  (Fig.  228)  will  some- 
times act  as  a  preventive  measure.  All  mental  reflex  irritation  must  be  guarded 
against.  Repeated  small  doses  of  the  bromids  or  of  opium  are  of  use  to  quiet 
the  irritable  state  of  the  uterine  muscle-fibers,  as  in  the  case  of  treatment  of 
abortion.  During  labor  the  early  use  of  chloroform  or  the  subcutaneous  use  of 
morphin  is  most  valuable,  and  all  bearing-down  efforts  on  the  part  of  the  patient 
must  be  discouraged.  She  should  be  placed  in  the  lateral  posture  or,  better 
still,  in  the  exaggerated  semi-prone  (see  Posture,  Part  X),  and  manual  retarda- 
tion of  the  head  at  the  pelvic  outlet  practised  if  necessary. 

II.  PROTRACTED  LABOR.     UTERINE  INERTIA. 

Definition. — Labor  prolonged  beyond  the  average  length  (page  448)  to  such 
an  extent  as  to  be  dangerous  to  mother  or  fetus ;  or  a  degree  of  uterine  contrac- 


MATERNAL-  DYSTOCIA   FROM   THE   FORCES.  569 

tion  insufficient  to  overcome  the  normal  resistance  or  that  produced  by  some 
abnormality.  Uterine  inertia  is  that  condition  in  which  the  uterine  contractions 
by  reason  of  their  weakness  or  irregularity  are  insufficient  to  dilate  the  os  in  the 
first  stage,  or  expel  the  fetus  in  the  second.  The  insufficiency  may  pertain  only 
to  a  certain  portion  of  the  uterus;  so  that  we  may  speak  of  partial  and  total 
inertia.  Thus  the  defective  action  may  be  confined  to  the  cervix.  Abdominal 
inertia  is  a  weak  or  inefficient  condition  of  the  abdominal  walls  which  renders 
the  patient  unable  to  aid  the  uterine  contractions  of  the  second  stage  by  her 
voluntary  forces  or  bearing-down  efforts.  Three  degrees  of  abdominal  inertia 
are  recognized;  namely,  simple  inertia,  exhaustion,  and  paresis.  From  the  date 
of  the  beginning  of  uterine  inertia,  whether  from  the  onset  of  labor  or  after  a 
period  of  normal  pains,  a  division  is  made  of  primary  and  secondary.  Primary 
or  true  uterine  inertia  is  that  condition  of  weak  pains  in  which  the  uterine  con- 
tractions have  been  inefficient  from  the  beginning  of  labor.  It  is  an  unusual 
variety  of  prolonged  labor.  Neither  mother  nor  fetus  need  necessarily  suffer. 
Secondary  inertia  or  uterine  exhaustion  is  a  gradual  or  sudden  cessation  of  strong 
uterine  contraction,  generally  in  the  second  stage.  Contractions  may  subse- 
quently recommence  spontaneously. 

Etiology. — The  causes  of  primary  inertia  do  not  coincide  with  those  of  the 
secondary  type.  The  former  might  arise  from  a  great  variety  of  conditions,  as 
follows:  (i)  Defective  innervation  (paralysis  of  the  nerve-centers  which  preside 
over  uterine  contractions);  (2)  defective  development  of  the  uterine  muscle; 
(3)  abnormal  shape  of  the  uterus,  as  in  uterus  bicornis;  (4)  abnormal  position 
of  the  uterus,  as  in  the  anteversion  which  accompanies  a  pendulous  abdomen, 
and  in  prolapse;  (5)  abnormal  distention  of  the  uterus,  as  in  hydramnios  or 
twins;  (6)  diseases  and  tumors  of  the  uterine  wall;  (7)  too  intimate  adhesions 
between  the  embryonal  sac  and  the  cavum  uteri.  Numerous  contributory 
factors  are  also  known  to  exist.  Uterine  inertia  is  thought  to  be  hered- 
itary. It  is  common  in  elderly  primiparae  and  in  mvdtiparas  who  have  gone 
many  years  without  becoming  pregnant.  On  the  other  hand,  we  see  inertia 
frequently  in  the  opposite  condition  of  too  frequent  labors.  As  a  rule,  we  find 
weak  pains  in  the  obese,  in  delicate  women,  in  invalids,  in  convalescents  from 
acute  infectious  diseases,  and  in  those  who  are  poorly  nourished  from  any  cause, 
especially  in  victims  of  hyperemesis  gravidarum.  Remediable  factors  are  found 
in  distended  bladder  and  rectum,  tympanites,  and  overloaded  stomach;  all  of 
which  have  been  known  to  impede  the  healthy  action  of  the  uterus.  Secondary 
inertia  occurs  more  frequently  than  primary.  It  is  common  in  primiparae 
whose  soft  parts  are  rigid,  and,  generally  speaking,  it  is  found  in  any  condition, 
whether  maternal  or  fetal  in  nature,  which  heightens  the  resistance  to  the  normal 
passage  of  the  child.  The  conditions  which  make  up  the  etiology  of  the 
obstructive  inertia  need  not  be  detailed  in  this  connection.  Partial  inertia  is 
due  usually  to  the  presence  of  some  local  lesion  or  tumor  of  the  uterus.  Abdom- 
inal inertia  occurs  in  the  presence  of  grave  diseases,  such  as  typhoid  fever  or 
tuberculosis ;  in  inanition  from  any  cause,  and  as  a  result  of  the  inhibitory  in- 
fluence of  pain  and  profound  mental  emotion. 

It  is  readily  apparent  that  primary  and  secondary  inertia  are  not  closely 
related,  the  latter  being  due  to  obstructive  conditions  which  at  times  must  exhaust 
the  most  vigorous  uterus.  For  this  reason  primary  inertia  is  sometimes  spoken  of 
as  true  or  essential  inertia,  while  the  secondary  form  is  characterized  rather  as  an 
exhaustion  or  paresis.  Still  the  two  forms  do  possess  some  features  in  common. 
Thus,  vigorous  contractions  often  readily  overcome  slight  degrees  of  obstruction 
which  could  determine  secondary  inertia  in  a  sluggish  uterus. 


570  PATHOLOGICAL   LABOR. 

Symptoms. — In  the  First  Stage. — One  of  the  first  symptoms  is  the  failure  of 
the  uterine  contractions  to  cause  progressive  dilatation  of  the  cervix.  Soon  the 
contractions  become  of  short  duration  with  longer  intervals;  they  are  accom- 
panied by  excessive  suffering,  giving  rise  to  the  expression  "painful  pains"; 
they  become  cramp-like  and  irregular,  and  finally  during  each  painful  contraction 
no  thinning  of  the  cervical  lip  or  protrusion  of  the  bag  of  membranes  occurs. 
Examination  of  a  primipara  will  usually  reveal  a  firm  cervical  ring  and  no  ap- 
parent obstacle  to  the  completion  of  the  first  stage,  provided  only  strong  uterine 
contractions  were  present.  In  the  case  of  a  multipara  the  contractions  present 
will  usually  be  less  painful,  with  long  intervals,  and  a  soft,  flabby  cervical  ring 
will  usually  be  found,  with  vaginal  walls  so  soft  and  readily  dilatable  that  it 
appears  that  only  a  few  contractions  accompanied  by  some  abdominal  efforts 
woiild  suffice  to  expel  the  fetus.  In  either  case  at  this  period  the  patient  may 
fall  asleep  and  efficient  contractions  may  not  recur  for  twelve  or  twenty-four 
hours.  For  a  long  period  there  are,  as  a  rule,  no  symptoms  beyond  the  mere 
delay  of  labor.  If  the  membranes  are  intact,  this  stage  may  persist  for  several 
days  without  serious  effects  upon  mother  or  child.  Some  fatigue  and  loss  of  sleep 
necessarily  result.  If,  however,  the  difficulty  is  found  to  be  due  to  some  condition 
of  the  cervix,  such  as  rigid  os,  exhaustion  will  ultimately  be  substituted  for  simple 
inertia.  (Exhaustion  is  considered  under  the  head  of  prolonged  labor  in  the  second 
stage  of  labor.)  In  case  of  premature  rupture  of  the  membranes  the  symptoms 
become  more  serious,  though  less  so  than  in  the  second  stage.  The  liquor  amnii 
escapes  slowly  and  the  futile  efforts  to  open  the  cervix  will  lead  to  exhaustion  at  a 
much  earlier  period  than  will  inertia  with  bag  of  waters  intact.  A  tetanic  contrac- 
tion of  the  uterus  may  be  present  during  the  first  and  second  stages  of  labor,  but 
this  is  not  the  rtde,  as  the  contractions  may  be  simply  weak,  irregular,  or  painful 
in  type.  Should  partial  or  complete  escape  of  the  liquor  amnii  ensue,  a  dangerous 
complication  results ;  for  even  should  the  head  for  a  time  act  as  a  ball- valve  and 
keep  back  some  of  the  water,  ''dry  labor''  is  always  to  be  feared,  with  its  tendency 
to  retraction  of  the  uterus,  ascent  of  the'contraction  ring,  dangerous  thinning  of 
the  lower  uterine  segment,  and  disturbance  of  the  utero-placental  circulation. 
What  contractions  now  remain  tend  not  to  cause  dilatation  and  expulsion  but 
a  further  thinning  of  the  lower  uterine  segment  and  finally  its  rupture. 

In  the  Second  Stage. — In  simple  protraction  of  the  second  stage  of  labor  the 
symptoms  at  the  outset  are  not  unlike  those  of  the  first  stage.  The  uterine 
contractions  may  be  weak  and  irregular  or  tetanic — usually  the  latter.  Inves- 
tigation may  show  that  the  auxiliary  forces  are  not  co-operating  with  the  uterus. 
There  may  be  no  bearing-down,  especially  in  cases  in  which  for  any  reason  the 
patient  is  unable  to  fix  her  diaphragm  (cardiac  or  pulmonary  disease) ;  or  when 
the  abdominal  wall  is  the  seat  of  any  structural  or  functional  disease  (oedema, 
corpulence) ;  or  when  fear  exerts  an  inhibitory  effect  upon  labor.  The  extreme 
pain  may  cause  the  woman  to  cry  out  unceasingly,  so  that  bearing-down  is  im- 
possible. Finally,  inertia  may  depend  upon  some  simple  local  condition  (an 
unemptied  bladder  or  rectum),  or  upon  some  psychical  cause  easily  remedied, 
as  the  presence  of  an  obnoxious  individual.  If  inertia  persists  during  the  second 
stage,  the  most  important  symptoms  may  have  reference  to  the  child,  who  will 
be  almost  certain  to  become  asphyxiated.  The  pressure  of  the  fetal  head  upon 
the  soft  parts,  which  will  cause  sloughing  if  continued,  does  not  betray  itself  by 
any  special  train  of  symptoms.  A  general  characteristic  of  inertia  in  the  second* 
stage  is  the  dry  condition  of  the  maternal  passages  from  the  failure  of  the  natural 
secretions  of  the  cervix  and  vagina. 

Exhaustion. — This  should  be  separately  considered,  for  while  primary  inertia 


MATERNAL'  DYSTOCIA   FROM   THE  FORCES.  571 

may  end  in  exhaustion  if  the  patient  is  not  relieved,  this  abortive  ending  of  labor  is 
more  commonly  a  result  of  obstruction  to  the  passage  of  the  child  in  the  presence 
of  contractions  of  the  uterus  originally  normal.  It  is  especially  in  these  obstruc- 
tive labors  that  a  peculiar  condition  of  the  uterus  is  prone  to  develop  which  is 
known  as  "continuous  action."  The  continuous  or  tetanic  action  of  the  uterus  is 
brought  about  as  follows :  The  abortive  contractions,  if  regular,  succeed  each  other 
with  progressively  diminishing  intervals  until  they  finally  merge  into  a  state  of 
tonic  contraction.  Experience  shows  that  in  simple  inertia  the  tetanic  state  super- 
venes rapidly ;  while  in  obstructive  conditions  with  strong  pains  it  is  deferred.  It 
is  important  to  distinguish  between  this  tetanic  state  and  simple  passivity  of  the 
uterus,  as  there  is  no  doubt  that  they  have  been  and  still  are  confounded.  Practi- 
cally the  tetanic  uterus  is  an  affair  of  the  second  stage  of  labor,  though  exceptions 
may  occur.  This  distinction  is  highly  important  in  practice,  as  oxytocics  are  ab- 
solutely contraindicated  in  the  tetanic  uterus.  The  symptoms  of  the  latter  are 
revealed  by  abdominal  palpation,  the  permanent  rigidity  of  the  womb  contrast- 
ing strongly  with  the  soft,  lax  structures  felt  when  the  uterus  is  merely  relaxed. 
Another  result  of  the  abortive  labor  pains  is  retraction  of  the  uterus  in  ob- 
structive cases,  which  is  brought  about  as  follows:  The  strong  contractions  of 
the  uterus  iiltimately  determine  a  stretching  of  the  lower  segment,  which  gives 
way  under  the  pressure  of  the  fetus.  As  the  cervix  stretches  the  body  undergoes 
a  corresponding  thickening,  and  the  retraction  ring  or  Bandl's  ring  shifts  its 
position  upward.  This  ring  sometimes  becomes  recognizable  by  external  palpa- 
tion, and  is  then  regarded  as  indicating  intervention,  but  not  version.  Retrac- 
tion of  the  upper  segment  as  just  described  is  said  to  occur  most  commonly  after 
early  rupture  of  the  membranes.  Inertia,  either  primary  or  secondary,  should 
not  be  confounded  with  non-advance  of  labor  from  undue  obliquity  of  the  uterine 
axis.  The  phenomena  of  exhaustion,  when  the  latter  is  once  established,  do  not 
differ  from  those  of  adynamia  in  general. 

Diagnosis. — Statements  of  the  woman  to  the  effect  that  the  pains  are  weak 
have  little  value.  Diagnosis  is  readily  made,  as  a  rule,  by  palpation,  which 
reveals  the  absence  of  a  natural  uterine  action,  and  by  the  arrest  of  labor.  If 
the  presenting  part  advances  slightly,  it  is  only  to  recede  again.  Upon  timing 
the  pains  they  are  found  to  be  very  short,  with  long  intermissions.  The  fetus 
exerts  active  movements  during  the  interval.  The  diagnostic  featiores  of  tetanic 
uterus  have  been  enumerated. 

Prognosis. — In  primary  inertia  the  prognosis  for  the  time  being  is  good  if  the 
bag  of  waters  does  not  rupture.  Before  rupture  of  the  membranes  the  first  stage 
of  labor  may  be  much  prolonged,  even  several  days,  without  serious  result  to 
mother  or  child,  although  this  favorable  ending  cannot  always  be  looked  for.  Ner- 
vous exhaustion  which  follows  the  suffering,  anxiety,  loss  of  sleep,  insufficient 
food,  etc.,  must  always  be  guarded  against,  for  extreme  exhaustion  predisposes  to 
subsequent  accidents  in  labor  and  the  puerperium.  If  the  waters  break  before  the 
dilatation  of  the  cervix,  an  additional  cause  of  inertia  is  supplied.  The  chief 
danger  to  the  fetus  is  found  in  the  prolonged  compression  of  the  skull  and  pla- 
centa, which  favors  the  development  of  asphyxia.  The  mother  is  threatened  with 
the  formation  of  a  passive  oedema  of  the  parts  in  advance  of  the  fetus,  which  in 
turn  predisposes  to  necrosis  and  the  eventual  development  of  fisttdas,  to  say 
nothing  of  the  added  dangers  of  infection.  It  must  not  be  forgotten  that  inertia 
has  been  known  to  terminate  in  precipitate  delivery.  This  can  hardly  be  due  to 
sudden  return  of  uterine  vigor,  but  to  the  fact  that  labor  has  progressed  more 
rapidly  than  the  physician  supposed.  Excessive  delay  in  the  second  stage  is 
always  dangerous  for  both  fetus  and  mother:  for  the  former  because  of  asphyxia 


572  PATHOLOGICAL   LABOR. 

from  compression  of  the  head  and  placenta;  for  the  latter  from  exhaustion, 
pressure  necrosis  and  fistulas,  rupture  of  the  uterus,  septic  conditions,  and 
post-partum  hemorrhage  from  uterine  atony. 

Treatment  in  the  First  Stage. — In  the  great  majority  of  cases  of  delayed  labor 
in  the  first  stage  there  is  no  real  obstruction  in  the  cervix.  The  latter  will  almost 
always  dilate  readily  enough  if  the  expulsive  powers  are  sufficiently  strong.  The 
first  principle  of  treatment  is  to  ascertain  the  cause  of  inertia  and  to  remove  it. 
This  may  be  a  distended  bladder  or  rectum,  or  the  excessive  pains  of  uterine 
contraction,  especially  when  spasmodic  in  character.  As  the  invariable  indica- 
tion is  to  accelerate  the  first  stage  of  labor,  any  legitimate  means  at  our  disposal 
may  prove  of  service,  and  our  resources  may  be  divided  into  two  groups:  (i) 
Those  applied  outside  the  parturient  canal,  and  (2)  those  which  we  make  use 
of  within  the  passages.  As  a  general  principle,  we  should  avoid  recourse  to  the 
second  group  as  far  as  possible. 

(i)  Means  for  Accelerating  the  Ftrst  Stage  of  Labor,  which  are  Applied  without 
the  Passages. — All  our  resources  should  be  set  in  operation,  even  those  of  the 
simplest  character.  Rest,  a  short  sleep,  feeding,  and  stimulation  are  all  of  benefit. 
Exercise  in  the  form  of  walking  is  often  of  value.  It  not  only  strengthens 
feeble  contractions,  but  when  the  latter  have  ceased  for  a  time, — which  often 
happens  after  early  rupture  of  the  membranes, — it  brings  about  their  reappear- 
ance, doubtless  through  reflex  excitation  by  the  weight  of  the  presenting  part 
on  the  lower  uterine  segment.  Other  postural  resources,  such  as  the  squatting 
position,  cannot  be  recommended  because  of  the  danger  of  prolapse  of  the  cord. 
The  physician  must  not  overlook  the  possibility  that  the  cause  of  inertia  may 
be  found  in  a  distended  bladder  or  rectum,  and  must  guard  against  such  a 
contingency.  Heat  is  a  valuable  stimulant  to  the  sluggish  uterus,  and  may 
be  administered  in  the  form  of  a  general  shower  or  douche  bath  or  hot  com- 
presses applied  over  the  sacriim  and  hypogastrium.  In  the  latter  form  the  action 
of  the  heat  is  reinforced  by  alternation  with  cold.  A  large  number  of  oxytocic 
drugs  have  been  used,  some  for  stimulant,  others  for  sedative  action.  Ergot 
should  never  be  used  in  the  first  stage  of  labor;  it  should  be  given  only  after  the 
expulsion  of  the  placenta.  Quinine  is  largely  used  at  the  present  day,  and  acts 
probably  as  a  purely  nervous  stimulant.  When  the  stomach  is  irritable,  I  employ 
large  doses  of  the  bisiilphate  of  quinine  (grs.  xx  to  xxx)  in  rectal  suppositories.  A 
group  of  sedative  drugs  comprises  chloral,  tincture  of  gelsemium,  and  the  coal-tar 
products.-  These  are  indicated  in  irregular  and  painfiil  contractions.  Chloral  is 
now  in  almost  general  use.  Opium  appears  to  act  as  a  sedative  in  irritable  con- 
ditions and  as  a  stimulant  in  sluggishness.  General  anesthesia  is  contraindicated 
during  the  first  stage  of  labor,  but  the  inhalation  of  a  few  drops  of  ether  or  chloro- 
form is  often  employed  for  sedative  effect  in  irregular  and  painful  contractions. 
If  too  much  chloroform  is  inhaled,  the  action  is  too  pronounced  and  the  contrac- 
tions may  be  arrested  entirely.  On  this  account,  if  anesthetics  are  employed 
at  all,  ether  or  the  A.  C.  E.  mixture  should  be  preferred.  In  instances  in  which 
the  severe  pain  and  cramp-like  action  of  the  contractions  appear  to  interfere 
with  the  progress  of  cervical  dilatation,  I  have  found  that  pouring  a  small  quan- 
tity of  ether  into  an  Allis  inhaler,  and  allowing  the  patient  to  inhale  it,  controls 
the  suffering  quite  as  well  as  does  chloroform,  and  there  is  much  less  danger  of 
producing  inertia  uteri.  Cocaine  applied  directly  to  the  cervix  has  been  used  as  a 
local  anesthetic.  Manual  friction  of  the  fundus  uteri,  manual  expression  (Part  X), 
and  the  like  are  hardly  indicated  in  inertia  of  the  first  stage  unless  dilatation  of  the 
cervix  is  over  half  completed.  Voluntary  efforts  at  bearing-down  are  likewise  of 
little  service,  save  when  the  cervix  is  partly  dilated,  especially  in  multiparas,  and 


MATERNAL   DYSTOCIA   FROM   THE   FORCES.  573 

when  rupture  of  the  membranes  has  occurred.  I  have  abandoned  the  use  of  elec- 
tricity as  dangerous  to  the  fetus  in  the  first  stage  of  labor.  A  unique  resource, 
since  it  is  applicable  during  pregnancy  rather  than  in  the  midst  of  labor,  is  the 
continuous  use  of  strychnine  for  some  weeks  before  delivery.  This  is  more  than 
a  mere  oxytocic,  for  it  is  also  a  prophylactic  against  a  flabby  uterus  after  delivery. 
Its  special  field  appears  to  be  in  debilitated  women.  It  should  be  given  at  first 
in  doses  of  g-^  grain  three  times  daily,  beginning  at  not  less  than  four  or  more 
than  eight  weeks  before  the  expected  confinement.  One  week  before  the  date 
of  the  latter  the  dose  may  be  increased  to  jg-  or  even  -^^  grain.  I  have 
used  the  drug  in  this  manner  in  many  multiparse  with  a  history  of  feeble,  irreg- 
ular, and  faulty  uterine  contractions,  post-partum  hemorrhage,  or  severe  after- 
pains,  and  with  most  excellent  results.  Strychnine  is  also  of  use  during  the  first 
stage  of  labor  as  an  oxytocic,  but  then  should  be  given  hypodermatically.  The 
amount  given  is  -g-^^-  grain  every  fifteen  minutes  until  -2V  grain  has  been  taken. 

(2)  Means  for  Shortening  the  First  Stage  of  Labor  that  are  Used  within  the 
Passages. — It  may  be  that  the  uterus  responds  to  the  various  stimuli  but  the 
woman  has  become  exhausted  from  the  delay,  so  that  more  radical  intervention 
is  called  for.  We  must  have  made  sure  that  there  is  no  mechanical  defect; 
this  necessitates  a  careful  internal  exploration.  The  simplest  internal  resource 
is  the  hot  vaginal  douche,  especially  indicated  in  cases  in  which  the  lower  uterine 
segment  has  been  forced  downward  into  the  pelvis  with  resulting  incarceration 
between  the  fetal  head  and  the  bony  pelvis,  causing  oedema  of  the  os.  If  the 
cervix  is  partially  open  and  contractions  are  present  which  do  not  cause  any  pro- 
trusion of  the  bag  of  waters,  we  may  suspect  the  presence  of  adhesions  between 
the  membranes  and  the  uterine  wall.  This  condition  is  remedied  by  the  finger 
introduced  into  the  cervix  to  the  extent  of  two  joints,  and  swept  around 
within  the  ring  of  the  os.  In  primiparse  this  is  difficiilt  of  execution,  and  it 
may  first  be  necessary  to  push  the  fundus  downward  and  backward.  Care  must 
be  taken,  while  detaching  these  adhesions,  to  avoid  rupturing  the  membranes, 
which  is  not  so  likely  to  happen  if  the  finger  is  used  rather  than  a  catheter  with  sty- 
let. If  these  measures  are  unsuccessful,  intrauterine  irritation  in  some  form  must 
be  employed.  Bougies  introduced  between  the  membranes  and  the  uterine 
wall  and  allowed  to  remain  in  situ  are  attended  by  slow  and  uncertain  results. 
A  resource  attended  by  a  prompt  response  is  the  principle  which  underlies 
the  bags  of  Barnes  and  Champetier  de  Ribes;  these  devices  not  only  excite 
uterine  contractions,  but  dilate  the  cervix  as  well  (see  Part  X).  As  far  as 
the  simple  indication  of  accelerating  labor  is  concerned,  it  need  only  be  said 
that  the  principle  of  these  hydraulic  dilators  may  usually  be  dispensed  with, 
and  certainly  should  be  when  possible.  Some  authorities  regard  manual 
dilatation  of  the  cervix  for  simple  inertia  as  nothing  less  than  malpractice. 
However,  very  gentle  dilatation  intended  simply  to  stimulate  the  uterus 
is  a  rational  procedure  and  may  safely  be  done  with  the  fingers.  (See 
Manual  Dilatation  of  the  Cervix,  Part  X.)  It  is  especially  applicable  when 
the  OS  is  partly  dilated,  soft,  and  pushed  low  down  into  the  pelvis.  Incisions 
are  as  little  indicated  as  is  instrumental  dilatation.  If  an  emergency  arises  so 
that  the  indication  is  to  extract  the  child  at  once,  one  or  both  of  these  last- 
mentioned  procedures  may  be  required. 

In  the  Second  Stage. — After  cervical  dilatation,  the  treatment  of  delayed 
labor  usually  becomes  a  simple  matter  in  the  absence  of  maternal  or  fetal  ob- 
struction, and  resolves  itself  usually  into  the  application  of  the  forceps,  when 
the  positive  indication  shows  itself  either  on  the  part  of  the  fetus  or  on  that 
of  the  mother.     (Part  X.)     Occasionally  in  non-engagement  of  the  head  the 


574  PATHOLOGICAL   LABOR. 

choice  will  be  between  forceps  and  version.  (Part  X.)  Strychnine,  friction,  and 
compression  of  the  fundus,  encouraging  and  educating  the  patient  to  use  her 
voluntary  muscles  in  bearing-down,  will  in  many  instances  bring  the  head 
into  digital  control  in  the  vulva.  It  is  at  this  time  that  supplying  the  patient 
with  traction  straps  to  pull  on,  thereby  assisting  in  her  bearing-down  efforts, 
will  often  be  of  assistance. 


MATERNAL    DYSTOCIA    IN    THE   PARTURIENT  TRACT  AND 

ADNEXA. 

ill.  RETENTION  OF  PLACENTA  AND  MEMBRANES. 

Definition. — The  placenta  as  a  whole  with  its  membranes  is  said  to  be  retained 
when  these  structures  have  not  been  expelled  one  hour  after  the  birth  of  the 
child.  After  apparently  successful  termination  of  the  third  stage  of  labor 
placental  and  membranous  tissues  may  remain  behind,  especially  when  accessory 
formations,  as  secondary  placentee,  are  present. 

Etiology. — The  causes  of  retained  placenta  and  membranes  are  as  follows: 
(i)  Adhesion  of  the  placenta  (so-called  placenta  accreta),  which  is  due  to  a 
previous  endometritis  deciduae.  (See  page  191.)  This  adhesion,  which  is  seldom 
universal,  prevents  the  loosening  and  detachment  which  occur  naturally  in  the 
third  stage  of  labor.  (Figs.  568  to  571.)  It  often  happens  that  the  supposition 
of  an  adhesion  of  the  placenta  is  incorrect,  the  delay  being  purely  natural 
and  due  to  atony,  powerless  contraction,  etc.  Such  a  conclusion  may  be  arrived 
at  when  too  precipitate  efforts  at  manual  expression  are  not  rewarded.  True 
adhesion  is  very  rare  (Fig.  771).  (2)  Atony  of  the  uterus.  A  condition  of  inertia 
of  the  uterus  in  the  third  stage  of  labor  may  be  the  cause  of  retention  (Fig.  772). 
This  state  may  be  surmised  if  timely  efforts,  to  expel  the  placenta  by  Credo's 
method  are  unavailing.  (3)  Hour-glass  contraction.  By  this  expression  is  meant 
a  contraction  of  Bandl's  ring,  which  incarcerates  the  placenta,  the  fundus  uteri 
remaining  in  a  lax  condition  (Figs.  773  and  774).  Schauta  regards  this  condition  as 
one  of  atony  of  the  uterus  despite  the  contraction  of  the  ring.  (4)  Contraction 
of  the  external  os  (Fig.  775).  (5)  Tetanic  contractions  of  the  entire  uterus. 
This  condition,  which  has  been  seen  after  the  abuse  of  ergot,  incarcerates  the 
placenta  for  the  time  being  (Fig.  776).  (6)  Actual  incarceration  of  the  placenta 
without  regard  to  the  uterine  contractions  is  seen  in  certain  malformations  of 
the  uterus  (Figs.  456  to  465).  (7)  The  foregoing  causes  refer  to  the  entire  pla- 
centa, but  it  is  also  possible,  as  already  stated,  for  a  portion  of  the  placenta  or 
membranes  to  be  left  behind  through  unskilful  management  of  the  after-birth 
period,  and  also  despite  all  precautions. 

Symptoms  and  Diagnosis. — The  principal  symptom  is  naturally  the  non- 
expulsion  of  the  placenta.  If  complete  adhesion  is  present,  there  will  be  no 
hemorrhage.  Examination  of  the  fundus  by  palpation  enables  us  to  recognize 
the  presence  of  uterine  atony;  and  the  association  of  vigorous  contractions 
with  the  non-appearance  of  the  placenta  will  cause  us  to  suspect  the  presence 
of  adhesion.  More  or  less  hemorrhage  may  accompany  either  atony  or  partial 
adhesion.  In  hour-glass  contraction  the  fundus  feels  elastic,  like  an  inflated 
balloon.  After  apparent  expulsion  of  the  entire  ovum,  the  persistence  of  fragments 
of  the  decidual  structures  or  the  presence  of  a  placenta  succenturiata  might  be 
indicated  by  a  persistent  hemorrhage,  expulsion  of  bits  of  tissue,  after-pains,  etc. 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        575 

Treatment. — Prophylaxis:  This  complication  can  usually  be  prevented  by 
the  proper  management  of  the  second  and  third  stages  of  labor,  but  especially 
the  latter.  If  the  uterus  is  followed  down  with  the  hand  on  the  fundus  during 
the  second  stage  and  no  traction  is  made  upon  the  child  to  assist  delivery;  if 
the  fundus  is  carefully  held  during  the  third  stage  and  compression  exerted 


Fig.  771. — Retained  Placenta 
FROM  Adhesion  to  the  Uterine 
Wall. 


Fig.  772. — Retained  Placenta  from  Atony  of 
the  Uterus. 


\ 


Fig.   773. — Retained   Placenta   from  Tightening   of  the    Contraction    Ring. 
Form  of  "Hour-glass  Contraction." 


Onb 


only  after  the  lapse  of  half  an  hour,  and  then  only  during  uterine  contraction; 
if  no  traction  is  made  upon  the  cord  and  ergot  administered  only  after  the 
complete  emptying  of  the  uterus,  retention  of  the  whole  or  a  portion  of  the 
placenta  will  rarely  occur.  Curative  treatment:  This  will  depend  upon  the 
amount  of  hemorrhage  present.     In  the  presence  of  profuse  hemorrhage  with 


576 


PATHOLOGICAL   LABOR. 


retained   placenta  the  indication  is  to  empty  the  uterus  completely  by  the 
quickest  possible  means ;  for  complete  uterine  contraction  is  the  surest  means 


Fig.  774. — Retained  Placenta  from 
Irregular  Contractions  of  One 
Horn.  One  Form  of  "Hour-glass 
Contraction." 


Fig.  775. — Retained  Placenta  from  Tighten- 
ing OF  THE  External  Os.  Follows  the  abuse 
of  ergot.  A  common  cause  of  the  complica- 
tion. 


Fig.  776. — Retained    Placenta    from  Tet- 
anic Contractions  of  the  Entire  Uterus. 


Fig.  777. — Retention  of  Mem- 
branes. 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.       577 

to  close  the  vessels  and  so  to  control  the  hemorrhage.  Should  Crede's  method 
of  placental  expression  fail,  recourse  must  be  had  to  digital  or  manual  extrac- 
tion of  the  placenta.     (See  Operations,  Part  X.) 

IV.  POST-PARTUM  HEMORRHAGE. 

Definition. — Post-partum  hemorrhage  is  hemorrhage  from  any  portion  of 
the  parturient  canal  after  delivery  of  the  fetus.  Post-partum  hemorrhage 
proper  is  only  from  the  placental  site  (Fig.  778).  It  is  primary  or  immediate 
when  it  occurs  within  twenty-four  hours  after  the  expulsion  of  the  child.  It 
is  secondary  or  remote  when  it  occurs  at  any  time  during  the  puerperium  subse- 
quent to  the  first  twenty-four  hours.     Post-partum  hemorrhage  is  also  internal 


Fig.  778. — Diagram  showing  the  Four  Varieties  of  Post-partum  Hemorrhage. 

or  concealed,  and  external  or  open.  It  may  occur  from  the  cervix,  vagina,  or  the 
pelvic  floor  (Fig.  778).  The  typical  form  is  commonly  known  as  "flooding." 
Frequency. — Severe  cases  of  hemorrhage  are  not  common,  to  judge  from 
hospital  statistics;  but  it  must  be  remembered  that  proper  facilities  for  treat- 
ment are  there  always  at  hand.  This  is  by  no  means  always  the  case  in  private 
practice.  It  may  be  stated  in  general  that  the  complication  occurs  in  a  mild 
form  once  in  fifty  labors;  is  severe,  once  in  1000;  and  fatal,  once  in  5000.  I 
found  in  2200  cases  of  confinement, — 800  of  which  were  outdoor,  and  the  re- 
mainder hospital  cases, — that  post-partum  hemorrhage  occurred  in  104  cases, 
or  4.72  per  cent.  This  includes  mild,  severe,  and  fatal  cases.  The  frequency 
37 


578  PATHOLOGICAL  LABOR. 

of  the  accident  in  hospital  and  dispensary  practice  was  about  the  same.  Of 
these  cases,  33.65  per  cent,  were  in  primiparas;  60.57  in  multiparse,  and  5.76  per 
cent,  had  no  record  of  parity.  Of  the  hemorrhages,  25.96  per  cent,  occurred 
before  placental  delivery;  62.50  per  cent,  after  the  completion  of  the  third 
stage,  and  in  11.53  per  cent,  the  hemorrhage  took  place  both  before  and  after 
delivery  of  the  placenta.  Of  the  foregoing,  mild  cases  occurred  once  in  22 
labors;  severe  cases  once  in  550;  and  fatal  cases  once  in  7333  labors.  The 
great  frequency  of  the  complication  in  the  foregoing  cases  is  due  undoubtedly 
to  the  common  use  of  the  forceps  (see  Part  X)  and  to  the  mismanagement 
of  the  third  stage.  (Page  490.)  It  is  strange  that  this  accident  does  not  occur 
more  frequently,  especially  in  consideration  of  the  characteristic  structure 
of  the  uterine  walls,  and  the  alterations  which  have  taken  place  in  the  pelvic 
blood-vessels  and  tissues  during  pregnancy.  The  conservatism  of  Nature  is 
to  be  thanked  for  the  escape  of  so  many  puerperal  women. 

Mechanism. — The  three  processes  which  prevent  post-partum  hemorrhage 
from  occurring  more  frequently  than  it  does  are  (i)  changes  in  the  vessel  walls, 
(2)  changes  in  the  muscle-fibers  of  the  uterus,  and  (3)  changes  in  the  blood. 
In  pregnancy  the  blood-vessels  of  the  uterine  walls  and  of  the  broad  ligaments 
and  pelvic  fascia  are  enormously  dilated.  In  the  uterus  the  vessel-walls  grow 
very  thin,  and  the  external  coats  are  gradually  absorbed,  until  at  the  end  of 
pregnancy  the  intima  alone  is  left,  which  is  surrounded  by  the  hypertrophied 
muscle-fibers.  The  muscular  fibers  as  pregnancy  advances  arrange  themselves 
longitudinally  in  rows  so  as  to  form  canals,  in  which  the  vessels  run  to  join 
with  the  placental  vessels.  Besides  the  longitudinal  arrangement  of  the  fibers 
parallel  with  the  vessels,  the  fibers  in  the  latter  months  of  gestation  arrange 
themselves  so  as  to  form  strong  circular  bands  or  sphincters  encircling  the 
vascular  trunks.  Thus  each  vessel  runs  in  a  muscular  canal  made  up  of  con- 
tractile smooth  muscle-fibers,  and,  in  addition,  falciform,  sphincter-like  bands 
of  the  same  contractile  fibers  encircle  several  vascular  trunks.  This  is  well  rep- 
resented by  a  package  of  cigarettes.  There  each  individual  cigarette  is  surrounded 
by  its  paper  cover  and  the  whole  pack  by  its  strong  cover.  This  arrangement 
permits  perfect  obliteration  of  the  blood-channels  by  uterine  contraction. 
Besides,  the  intima  is  very  elastic,  which  gives  the  vessel -wall  the  property 
of  contractility,  by  which  the  ragged  edges  of  the  sinuses  retract  into  the  sub- 
stance of  the  uterus  which  covers  them  and  stops  up  the  apertures.  The  third 
process  in  Nature's  conservatism  is  the  increased  coagulability  of  the  blood. 
The  blood-current  is  slowed  in  the  great  sinuses,  and,  owing  to  this  and  the 
extreme  thinness  of  the  vessel-walls,  there  is  a  marked  tendency  to  diapedesis 
of  white  blood-corpuscles  which  proliferate  in  the  connective  tissue  around 
the  vessels  and  add  their  part  to  the  obstruction  of  the  lumina.  When,  there- 
fore, the  decidua  separates,  this  process  hinders  hemorrhage.  On  the  other 
hand,  there  are  (i)  cases  in  which  the  uterus  will  remain  comparatively  large 
and  flaccid  and  still  no  flooding  result.  (2)  In  many  cases  alternate  contraction 
and  relaxation  of  the  uterus  will  take  place  after  labor,  and  still  no  hemorrhage 
occur.  This  leads  to  the  consideration  of  another  preventive  factor — thrombosis. 
In  these  cases  of  incomplete  or  partial  contraction  of  the  uterus  the  organ 
has  sufficiently  contracted  to  allow  of  the  formation  of  coagula  in  the  mouths 
of  the  uterine  sinuses,  so  that  when  the  uterus  again  relaxes,  these  openings 
are  plugged  by  coagulated  blood. 

Etiology. — Predisposing  Causes. — Among  these  is  the  hemorrhagic  diathesis. 
Some  women  are  by  nature  "bleeders,"  and  all  through  their  pregnancy,  par- 
turition, and  puerperium  they  are  subject  to  hemorrhage.     Certain  conditions  of 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        579 

the  mother's  blood,  as  albuminuria,  extreme  malarial  poisoning,  leucocythemia, 
and  alcoholism,  strongly  predispose  to  hemorrhage.  Certain  conditions  of  the 
liver,  heart,  and  lungs  which  retard  or  obstruct  the  return  circulation  are  also  pre- 
disposing causes.  It  is  more  common  in  multiparae  than  in  primiparae;  in  2200 
confinements,  I  found  this  hemorrhage  twice  as  frequent  in  the  former  (60.57  per 
cent.)  as  in  the  latter  (33.65  per  cent.).  It  is  apt  to  occur  in  those  in  whom  men- 
struation is  generally  profuse — in  women  of  a  delicate  constitution.  Thus  it  is  ' 
seen  among  the  rich  rather  than  among  the  hard-working  classes;  in  delicately 
nurtured  women  who  have  cultivated  the  emotional  at  the  expense  of  the  phy- 
sical. It  also  occurs  in  women  of  the  temperate  zones  who  have  taken  up  their 
residence  in  the  tropics  and  have  become  debilitated  by  the  warm  climate.  Irregu- 
larities in  the  maternal  forces,  such  as  precipitate  or  protracted  labor,  also  lead 
to  post-partum  hemorrhage;  so  does  overdistention  of  the  uterus,  as  in  multiple 
pregnancies  and  hydramnios.  Certain  conditions  of  the  muscular  walls  of  the 
uterus,  degenerations,  tumors;  or  malposition  of  the  organ,  partial  or  com- 
plete inversion,  also  favor  post-partum  hemorrhage. 

Exciting  Causes. — Foremost  among  these  is  the  improper  treatment  of 
the  second  and  third  stages  of  labor.  This  complication  is,  almost  without 
exception,  the  attendant's  fault,  and  applies  to  the  too  rapid  emptying  of 
the  uterus,  as  in  extraction  in  breech  presentations,  and  the  use  of  forceps, 
cranioclasts,  or  cephalotribe,  or  by  too  rapid  extraction  after  turning,  and 
the  excessive  use  of  anesthetics — chloroform  or  ether.  Here  also  belong  efforts 
on  the  part  of  the  attendant  to  hurry  delivery  by  uterine  compression,  and 
injudicious  voluntary  efforts  on  the  part  of  the  patient  during  the  second  stage; 
as,  for  example,  too  forcible  bearing-down  during  the  hard  pains.  Mental 
emotions,  such  as  anger,  fright,  anxiety,  and  such  disturbances  as  coughing, 
laughing,  vomiting,  defecation,  etc.,  have  been  known  to  give  rise  to  post-partum 
hemorrhage.  A  distended  bladder  or  rectum  often  constitutes  an  exciting  cause. 
The  retention  of  the  placenta,  membranes,  or  blood-clots,  or  new  growths 
in  the  uterus,  may  hinder  its  contraction.  A  uterus  completely  and  perma- 
nently contracted  cannot  give  rise  to  a  severe  hemorrhage.  Other  factors  are: 
uterine  apathy;  imperfect  development  of  the  organ  or  a  deficient  nerve- 
• -supply  to  it;  adherent  placental  tissue;  a  large  pyosalpinx,  h3'-drosalpinx, 
pelvic  exudate,  old  adhesions  of  the  peritoneal  surface  of  the  uterus,  or  any 
mechanical  obstruction  to  uterine  contraction.  Placenta  prsevia  may  be  the 
cause  of  post-partum  hemorrhage,  for  the  lower  uterine  segment  has  not  the 
power  to  contract  that  the  upper  part  of  the  organ  has,  hence  when  the  placenta 
is  attached  here  the  open  mouths  of  the  vessels  do  not  close  so  quickly. 

Symptoms. — The  symptoms  in  many  cases  come  insidiously — all  may 
apparently  have  gone  well,  and  the  placenta  expelled  naturally,  but  soon  after, 
the  first  symptom  perhaps  will  be  a  complaint  from  the  patient  that  she  "feels 
faint,"  and  that  "something  is  flowing  away  from  her."  This  warning  should 
never  be  disregarded,  and  an  immediate  examination  should  be  made.  There 
may  be  only  a  slight  discharge  or  the  blood  may  be  escaping  in  torrents.  On 
palpating  the  uterus  it  is  found  to  be  soft,  flaccid,  and  flabby,  rising  to  and 
perhaps  above  the  umbilicus,  and  presenting  hard,  irregular  prominences  which 
shift  their  position  under  a  firm  grasp.  These  are  blood-clots  within  the  uterus. 
In  the  more  severe  cases  in  which  uterine  inertia  is  complete,  external  pal- 
pation will  not  discover  any  uterus  at  all.  Alternate  contractions  and  re- 
laxations of  the  uterus,  together  with  pain  and  tenderness  when  the  fundus 
is  firmly  grasped,  are  certain  signs  of  hemorrhage  from  atony  of  the  muscular 
fibers.     There  may  be  slight  open  or  external  hemorrhages  taking  place  for 


580  PATHOLOGICAL   LABOR. 

some  time  before  any  general  symptoms  are  produced,  and  the  patient  not 
complaining,  the  physical  signs  will  be  overlooked.  In  extreme  cases,  however, 
of  the  concealed  or  the  open  variety,  the  general  symptoms  of  shock  and  col- 
lapse set  in,  and  it  seems  impossible  to  cause  the  uterus  to  contract  immediately. 
In  sudden  profuse  hemorrhages  death  may  occur  within  two  or  three  minutes. 
Frequency  of  the  pulse-rate  and  decreased  force  are  valuable  danger-signals 
of  the  condition,  and  when  observed  should  demand  a  careful  examination  of 
the  uterus  and  the  discharge. 

Diagnosis. — The  diagnosis  is  generally  plain,  especially  when  the  bleeding 
is  external.  It  is  different  when  the  blood  accumulates  within  the  uterine 
cavity,  which  constitutes  the  concealed  variety,  for  although  there  are  then 
the  symptoms  of  syncope  and  collapse  and  a  more  or  less  rapidly  enlarging 
abdomen,  yet  these  symptoms  and  signs  may  be  present  without  internal 
hemorrhage,  (i)  Syncope  occurring  after  labor  does  not  always  depend  upon 
loss  of  blood.  It  is  often  observed  after  precipitate  and  very  rapid  labors, 
for  in  these  cases  the  uterus  is  so  quickly  emptied  that  the  pressure  to  which 
the  abdominal  vessels  has  been  subjected  in  the  last  two  months  of  pregnancy 
is  suddenly  removed;  the  circulation  in  them  becomes  free  and  unobstructed 
and  there  is  a  rapid  determination  of  blood  from  the  upper  part  of  the  body, 
giving  rise  to  cerebral  anemia  and  fainting.  When  this  occurs,  raising  the 
foot  of  the  bed  and  the  application  of  a  moderately  tight  abdominal  bandage 
will  usually  relieve  the  condition.  (2)  Enlargement  of  the  abdomen  may  be 
owing  to  the  fact  that  the  intestines,  being  suddenly  relieved  of  pressure  and 
distended  by  gas,  cause  the  abdominal  wall  to  swell  up  nearly  to  its  previous 
size.  But  in  this  case  careful  physical  examination  by  palpation,  percus- 
sion, and  vaginal  touch  will  readily  determine  the  true  state  of  affairs.  (3) 
An  hysterical  attack  coming  on  immediately  after  labor  may  be  mistaken  for 
the  general  symptoms  of  hemorrhage;  but  physical  examination  will  again 
distingmsh  the  well-contracted  uterus  in  the  hypogastrium.  (4)  Lacerations 
of  the  cervix  causing  rupture  of  the  circular  artery  or  lacerations  of  the  genital 
tract  below  the  cervix  may  be  mistaken  for  post-partum  hemorrhage.  In  these 
cases  there  will  be  a  firmly  contracted  uterus.  If  any  doubt  exists,  a  speculum 
can  be  passed  and  the  bleeding  point  treated.  If  the  hemorrhage  does  not 
occur  within  ten  or  fifteen  minutes  of  the  birth  of  the  child,  it  is  not  usually 
due  to  cervical  or  vaginal  tears.  Engel  (1840),  Schraeder,  Virchow,  Valenta, 
and  Olshausen  have  described  a  dangerous  variety  of  hemorrhage:  viz.,  in 
cases  in  which,  although  the  rest  of  the  uterus  is  firmly  contracted,  the  place 
of  placental  insertion  does  not  participate,  and  there  results  what  might  be 
termed  paralysis  of  the  placental  site.  The  part  involved  is  driven  down 
into  the  uterine  cavity  by  the  uterine  parenchyma  which  is  contracted  about 
it  like  a  ring,  and  thus  a  sort  of  tumor  is  formed  which  projects  into  the  uterine 
cavity,  and  at  a  corresponding  point  upon  its  external  surface  a  depression 
may  be  made  out  by  careful  palpation.  This  variety  is  particularly  danger- 
ous, because,  the  greater  part  of  the  uterine  globe  being  firmly  contracted, 
this  small  relaxed  part  may  escape  observation.  Rarely  an  uncontrollable 
post-partum  hemorrhage  occurs  from  a  firmly  contracted  and  uninjured  uterus. 
One  case  is  on  record  in  which  it  occurred  from  an  aneurysmal  vessel;  another 
from  a  rupture  hematoma  of  the  cervix;  and  a  third  from  a  lacerated  varicose 
cervical  vein.  These  complications  are  said  to  be  more  common  in  high  than 
in  low  altitudes  on  account  of  lessened  atmospheric  pressure  (Hirst). 

Prognosis. — The  prognosis  is  doubtful,  as  it  depends  on  several  factors.  It 
is  the  graver,  the  earlier  the  hemorrhage  takes  place.     There  is  great  danger  in 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.       581 

that  variety  in  which  by  the  formation  of  a  vaginal  or  cervical  clot  or  the  intro- 
duction of  a  tampon  it  becomes  hidden.  If  the  blood  is  like  serum,  not  clotting, 
there  is  immediate  danger  of  death.  Pain  in  the  back  is  taken  as  an  encouraging 
sign  indicating  uterine  activity.  Other  things  being  equal,  the  prognosis  is 
more  dangerous  in  the  internal  variety  than  in  the  external,  for  in  the  former 
the  flow  is  apt  to  escape  detection.  There,  again,  the  prognosis  will  vary 
depending  on  the  completeness  of  the  uterine  inertia,  and  whether  the  patient 
is  to  have  immediate  and  skilful  treatment,  for  a  very  few  moments  may  decide 


Fig.   779. — Compression  of  the  Fundus  for  the  Emptying  of  the  Uterus  and  thb 
Control  of  Post-partum  Hemorrhage. 


the  patient's  fate.     The  late  results  of  the  hemorrhage  are  the  same  as  those 
from  any  severe  hemorrhage. 

■  Treatment. — Preventive. — In  case  the  pregnant  woman  is  suffering  from 
albuminuria,  leucocythemia,  or  alcoholism,  the  condition  should  be  treated, 
so  that  when  the  time  of  delivery  draws  near,  the  nervous,  muscular,  and  cir- 
culatory systems  of  the  patient  may  be  in  as  good  a  condition  as  possible. 
All  causes  of  obstructed  venous  return  should  be  sought  out,  whether  resident 
in  the  liver,  heart,  or  lungs,  and  remedied  as  far  as  possible.  Women  worn 
out  with  frequent  child-bearing  and  the  attendant  nursing  and  anxiety  should 


582 


PATHOLOGICAL   LABOR. 


be  strengthened  by  iron»  fresh  air,  nourishing  food,  and  moderate  exercise. 
When  there  is  reason  to  fear  precipitate  labor,  the  patient  should  not  go  about 
without  a  nurse  properly  qualified  to  manage  the  delivery.  In  attending 
such  a  case  before  the  child's  birth,  delay  should  rather  be  encouraged  so  that 
the  uterus  may  not  be  emptied  too  rapidly  and  the  danger  of  uterine  inertia, 
increased.  In  cases  of  protracted  labor  the  physician  should  not  delay  till 
the  patient  is  exhausted  before  he  renders  assistance.  A  case  of  hydramnios 
should  not  run  too  far;  rather  should  the  membranes  be  ruptured  when  labor 
appears  about  to  progress  smoothly.     The  most  important  part  of  the  pre- 


Fig.  780. — Bimanual  Compression  of  the  Uterus  for  the  Control  of  Post-partui* 
Hemorrhage.  The  fingers  of  the  left  hand  can,  at  the  same  time,  compress  the 
abdominal  aorta. 


ventive  treatment  is  the  proper  management  of  the  second  and  third  stages- 
of  labor.  The  hand  should  not  leave  the  fundus  after  the  birth  of  the  child 
till  the  placenta  is  expelled,  and  uterine  contractions  should  be  watched  care- 
fully afterward  for  at  least  an  hour.  Any  disturbance  of  the  patient  during 
this  time  should  be  avoided,  and  the  administration  of  a  drachm  of  the  fluid 
extract  of  ergot  after  complete  emptying  of  the  uterus  adds  to  the  safety  and 
comfort  of  the  woman.  The  placenta  and  membranes  should  be  carefully 
examined  after  their  expulsion.  An  abdominal  binder  should  be  applied  im- 
mediately and  the  child  placed  to  the  breast  within  three  hours  of  the  com- 
pletion of  labor. 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        583 

Curative  Treatment. — The  curative  treatment  is  more  satisfactory  than 
that  of  any  other  obstetrical  complication.  The  mechanism  by  which  the 
condition  occurs  must  be  carefully  borne  in  mind;  whence  it  will  appear  that 
successful  management  must  fulfill  three  indications:  viz.,  (i)  The  uterus 
must  be  evacuated,  (2)  it  must  be  made  to  contract  completely;  (3)  the  loss 
of  blood  and  its  consequences  must  be  made  good  by  measures  directed  to 
the  relief  of  the  acute  anemia,     (i)  Evacuation  of  the  uterus:  The  uterus  in  these 


Fig.  781. — Bimanual  Compression  of  the  Uterus.  The  Left  Hand,  in  the  Shape 
OF  A  Fist,  is  Introduced  into  the  Uterine  Cavity,  and  This  is  Grasped'by 
THE  Right  Hand  through  the  Anterior  Abdominal  Wall. 


cases  usually  contains  fragments  of  placenta,  membranes,  or  blood-clots  which 
must  be  brought  away.  Credo's  movements  (See  Operations)  are  therefore 
instituted  in  the  same  manner  as  in  the  expulsion  of  the  placenta  (Fig.  779). 
In  kneading  the  uterus  the  fundus  is  at  the  same  time  compressed,  while  the 
ulnar  border  of  the  operator's  hand  makes  pressure  on  the  abdominal  aorta. 
The  hand  is  introduced  into  the  uterine  cavity  only  when  the  Cred^  method 
fails  in  its  purpose.     (2)  Permanent  contraction  of  the  ^lter us:  The  rules  for  bring- 


584  PATHOLOGICAL  LABOR. 

ing  this  about  are  in  part  a  continuation  of  the  preceding.  Compression  of 
the  fundus  uteri  and  of  the  aorta  is  maintained,  or  Breisky's  method  of  bimanual 
compression  of  the  uterus  may  be  employed  alternately  (Fig.  780).  The  uterine 
cavity  should  be  douched  with  hot  water,  either  plain  or  with  the  addition  of 
I  per  cent,  acetic  acid.  About  one  quart  of  water  should  be  injected  at  a  tem- 
perature of  120°  F.  (49°  C).  In  an  emergency  hot  or  cold  vinegar  may  be  used 
in  place  of  the  acidulated  water.  The  alternate  use  of  hot  and  cold  water  or  ice 
has  been  advocated  in  these  cases,  but  cold  in  the  uterus  is  a  depressant  and  adds 
to  the  shock  of  the  hemorrhage.  There  is  no  objection,  however,  to  the  applica- 
tion of  cold  to  the  vulva.  Another  method  of  bimanual  compression  (Gooch's)  is 
also  recommended  (Fig.  781).  It  consists  in  compressing  the  fundus  with  one  h^nd 
while  the  other,  tightly  closed,  occupies  the  uterine  cavity.  When  for,  any  reason 
the  hand  is  introduced  within  the  uterus,  it  should  be  withdrawn  only  during  a 
contraction  lest  air  entering  a  sinus  cause  fatal  pulmonary  embolism.  The  man- 
agement thus  far  given  should  be  sufficient  in  most  cases  to  arrest  all  hemorrhage. 
It  is  eminently  natural  management,  since  it  aids  and  imitates  Nature's  methods. 
However,  it  is  not  invariably  successful,  for  a  degree  of  atony  sometimes  exists 
which  cannot  be  made  to  yield  to  mechanical  excitation.  If  the  styptic  douche 
and  Gooch's  method  are  ineffectual,  the  uterine  cavity  and  the  vagina  must  be 
tamponed  with  gauze.  (See  Tamponade  of  Uterus,  Operations,  Part  X.)  The 
tampons  should  be  removed  in  about  six  hours.  As  an  adjuvant  to  the  measures 
just  described,  ergotin  may  be  injected  subcutaneously.  Styptics  to  the  uterine 
cavity  are  contraindicated  with  the  exception  of  those  enumerated.  (3)  Treat- 
ment of  anemia  and  shock:  This  is  directed  especially  to  the  acute  anemia  and 
tendency  to  heart  failure  which  are  produced  by  loss  of  blood.  If  the  severity 
of  the  symptoms  is  such  as  to  warrant  the  most  active  treatment,  the  pillows 
are  removed  from  the  bed,  the  foot  of  the  bedstead  is  elevated,  and  the  patient's 
arms  and  legs  are  bandaged  (autotransfusion).  Warm  saline  infusion  is  then 
introduced  into  the  rectum  and  subcutaneously  beneath  the  breasts.  (See 
Operations,  Part  X.)  Stimulants  must  be  used  with  care  owing  to  their  tend- 
ency to  cramp  the  heart  under  these  circumstances.  Ammonia  may  be  injected 
into  a  vein,  and  camphorated  oil  subcutaneously.  Absolute  quiet  is  demanded. 
Feeding  must  not  be  neglected  in  these  cases.  At  first  it  may  require  limitation 
to  sips  of  brandy  and  coffee  every  fifteen  minutes;  after  some  reaction  has  set 
in,  beef -juice,  panopeptone,  mutton  broth,  etc.,  may  be  substituted.  In  case 
of  vomiting  the  patient  may  be  nourished  by  the  rectum  with  enemata  of  hot 
water  containing  whisky  and  pancreatinized  milk  or  panopeptone. 

V.  RUPTURE  OF  THE  UTERUS. 

Definition. — A  partial  or  complete  rupture  of  some  part  of  the  uterine  wall 
occurring  during  pregnancy,  labor,  or  the  puerperium.  So-called  spontaneous 
rupture  may  occur  during  pregnancy  from  rapid  stretching  of  the  uterine  walls 
or  from  cystic  degeneration  of  the  chorion.  These  latter  ruptures  are  very 
rare  and  result  almost  invariably  from  traumatism.  Intra-partum  rupture  is 
rupture  of  the  uterus  proper.  Rupture  may  also  occur  during  the  puerperium 
from  a  dissecting  metritis  in  septic  conditions,  or  from  sloughing  following 
prolonged  pressure  of  the  fetal  head  during  labor.  This  is  also  very  rare  and 
is  nearly  always  traumatic,  e.  g.,  from  post-partum  curettage. 

Frequency. — It  occurs  about  once  in  1000  cases  of  confinement.  A  case 
might  not  be  met  with  in  a  decade,  while,  again,  one  observer  might  see  two 
in  the  same  day.     However,  this  accident  is  far  more  frequent  than  is  generally 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.         585 

stated.  A  great  proportion  of  those  in  private  practice  which  end  fatally 
are  reported  as  post-partum  hemorrhage  or  as  septic  peritonitis.  It  is  only 
in  maternity  hospitals  that  anything  like  correct  statistics  can  be  compiled. 

Pathology. — On  account  of  the  general  right  obliquity  of  the  uterus,  the 
retraction  is  greater  on  the  left  side  than  on  the  right.  In  shoulder  presenta- 
tion, also,  the  head  is  most  often  on  the  left.  These  facts  probably  explain 
the  general  direction  of  the  ruptures  and  their  greater  frequency  on  the  left 
side.  The  cause  for  the  frequency  of  rupture  on  the  posterior  wall  is  the  direc- 
tion of  the  force  of  uterine  contractions.  When  the  rupture  is  in  the  lateral 
wall,  the  peritoneum  is  generally  felt  intact,  for  its  attachment  in  this  situation 
is  loose  and  the  folds  of  the  broad  ligament  near  the  uterus  are  separated  to 
a  certain  degree  by  the  growth  of  that  organ  during  pregnancy.  As  a  rule 
the  edges  of  the  rupture  are  not  clean-cut,  but  are  rough  and  jagged,  and  the 
direction  is  often  oblique  (Fig.  783).  The  prevailing  low  situation  of  the  rupture 
depends  on  the  greater  distention  and  thinning  of  this  part  of  the  uterus  during 
labor  (Figs.  530  and  531).  The  degree  of  the  tear  varies  from  the  size  of  a 
finger-tip  to  an  opening  large  enough  for  the  fetus  to  pass  through.  A  trans- 
verse rupture  sometimes  embraces  all  or  nearly  all  of  the  circumference  of 
the  organ  (Fig.  783);  a  longitudinal  or  oblique  tear  may  extend  downward 
into  the  vagina  or  upward  into  the  fundus  of  the  uterus  (Fig.  782).  If  the 
rupture  is  quite  large  and  the  uterine  contents  are  evacuated,  the  upper  part 
of  the  organ  firmly  contracts,  while  it  is  forced  out  of  its  normal  position  by 
the  fetal  body,  which  lies  in  the  abdominal  cavity.  The  manner  of  escape 
of  the  fetus  varies  in  different  cases.  In  a  large  tear  it,  together  with  the  pla- 
centa, may  be  extruded  into  the  cavity;  or,  again,  if  its  head  is  impacted  in 
the  pelvis,  it  may  be  only  the  trunk  and  extremities  which  lie  outside  the  uterus. 
In  some  cases  the  placenta  remains  in  the  uterus  and  is  delivered  through  the 
vagina.  Incomplete  rupture  consists  of  partial  or  almost  complete  rupture  of  the 
muscular  coat.  Complete  rupture  involves  muscle  and  peritoneum.  From  the 
former  may  result  extrauterine  and  extraperitoneal  hematocele.  Very  rarely 
rupture  of  the  peritoneum  alone  occurs.  The  complete  rupture  consists  in 
a  communication  between  the  cavities  of  the  uterus  and  peritoneum.  The 
rupture  is  called  complicated  when  there  is  associated  an  injury  of  a  neighbor- 
ing organ;  for  example,  an  opening  into  the  bladder  or  intestines. 

Etiology. — Among  the  predisposing  causes  are  disproportionate  size  of  the 
head  and  pelvis,  stretching  of  one  side  of  the  lower  uterine  segment  from  lateral 
displacement,  and  any  force  which  tends  to  twist  the  organ  upon  its  longitudinal 
axis.  Schuchard  (1884)  found  among  73  cases  of  hydrocephalus,  14  cases 
of  rupture  of  the  uterus.  A  shoulder  presentation  is  responsible  for  a  large 
proportion  of  cases  of  rupture  of  the  uterus,  and  it  is  possible  for  the  cervix 
to  be  so  rigid  that  rupture  occurs  before  the  cervix  yields.  Contributory 
causes  of  rupture  are  anything  which  narrows  and  makes  rigid  the  cervical 
or  vaginal  canals  (healed  fistulas  or  lacerations,  new  growths,  etc.);  pathological 
change  in  the  uterine  tissue  (syphilis,  soft  myoma,  carcinoma).  Placenta 
prasvia  may  also  act  as  a  cause.  The  scar  of  a  previous  Cesarean  section 
has  been  known  to  be  a  cause.  Rupture  occurs  seven  times  as  often  among 
multiparas  as  among  primiparae.  Among  19  cases  Bandl  found  2  primiparae, 
and  others  have  given  the  percentage  of  primiparag  as  12  or  less. 

The  exciting  causes  include  the  unintelligent  use  of  ergot.  A  number  of 
cases  of  rupture  have  occurred  from  intrauterine  manipulation,  curettage, 
version,  extraction  of  placenta,  etc.,  criminal  abortion.  Rupture  occurring 
during  pregnancy  is  due  to  some  pathological  change  in  the  uterine  wall  or 


586 


PATHOLOGICAL   LABOR. 


to  a  new  growth.  Wittrow  (1891)  reported  a  case  of  rupture  from  external 
violence.  The  peritoneum  and  the  muscular  coats  were  torn  but  not  the  mucosa. 
Cases  of  rupture  have  been  reported  which  occurred  after  the  placenta  was 
removed,  from  clumsy  and  violent  manipulations  by  the  accoucheur  or  mid- 
wife. The  site  of  the  rupture  is  usually  lateral  and  on  the  left  side,  correspond- 
ing to  the  position  of  the  vertex.  The  body  of  the  organ  is  seldom  torn.  There 
are  two  methods  in  the  mechanism  of  spontaneous  rupture:    (i)  Rupture  by 


OVAR/AN 
VESSELS 


f^TERIOR 
URFACE 


NTERNAL  OS 


UTERINE       yH^ 

vesseTs 


\^ 


EXTERNAL  OS  '  '^ 


Fig.  782. — Longitudinal  Rupture  of  the  Uterus,  Following  Manual  Dilatation 
OF  the  Os  in  Placenta  Pr^evia.  Tearing  of  the  main  branches  of  the  uterine  artery 
and  death  from  internal  hemorrhage.  Note  that  the  cervical  canal  and  the  limit 
of  the  internal  os  are  still  present. — (Author's  case.) 


thinning  of  the  lower  segment.  In  proportion  to  the  variation  between  the 
expelling  power  and  the  resistance,  thinning  of  the  lower  segment  takes  place 
while  it  closely  hugs  the  enclosed  fetus  until  rupture  occurs.  (2)  Rupture  by 
compression  of  the  uterine  wall.  The  wall  sometimes  ruptures  from  the  com- 
pression to  which  it  IS  subjected  between  the  bony  pelvis  and  the  presenting 
part. 

Symptoms. — Impending:  The  most  characteristic  symptoms  are  the  ascent 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        587 

of  the  contraction  ring  and  the  tension  and  tenderness  of  the  round  Hgaments. 
Pulse  and  temperature  may  not  be  changed,  but  the  patient  may  develop 
great  anxiety  and  restlessness.  Thickening  of  the  upper  portion  of  the  uterus, 
and  a  transverse  groove  across  the  lower  portion,  can  often  be  recognized  through 
the  abdominal  wall,  the  latter  just  above  the  pubis.  The  uterine  contractions 
will  be  strong  or  even  tetanic,  in  either  case  accompanied  by  intense  pain. 
There  is  often  a  history  of  previous  prolonged,  obstructed  labor  due  to  pelvic 


\Round  ligament. 
\Main  branch  of  uterine 
artery  dra'wn  uy.  _._: 


^a«.. 


Fig.  783. — Transverse  or  Oblique  Rupture  of  the  Uterus  and  Tearing  of  a  Main 
Branch  of  the  Left  Uterine  Artery.  Death  from  internal  hemorrhage  and  shock 
a  short  time  after  being  received  into  the  Emergency  Hospital.  Case  had  been  treated 
for  inertia  with  ergot  by  a  midwife. — {Author's  case.) 


deformity,  with  entire  escape  of  the  liquor  amnii  causing  dry  labor.  The 
symptoms  of  rupture  are  very  characteristic,  especially  when  complete.  There 
is  a  sharp,  acute  pain;  a  sudden  cry  from  the  patient;  sometimes  a  sound  of 
tearing  tissue ;  followed  by  immediate  collapse  and  symptoms  of  internal 
hemorrhage.  External  hemorrhage,  recession  of  the  presenting  part,  prolapse 
of  the  intestines,  and  subperitoneal .  emphysema  are  sometimes  present.  Col- 
lapse is  soon  marked,  the  pain  severe,  the  pulse  small  and  rapid,  the  patient 


588 


PATHOLOGICAL   LABOR. 


usually  vomits  and  the  uterine  contractions  cease,  though  the  latter  is  not  an 
invariable  occurrence.  In  the  case  of  a  head  presentation  the  head  often  recedes 
from  the  pelvis  even  if  it  is  alread}''  engaged.  In  shoulder  presentation  the 
head  may  sometimes  be  felt  through  the  tear,  and  it  will  be  noted  that  the 
form  of  the  uterus  has  suddenly  altered.  In  some  cases  the  fetus  may  leave 
the  uterus  entirely  and  may  be  palpable  through  the  abdominal  walls.  Even 
in  rupture  of  considerable  extent  the  hemorrhage  may  be  slight  or  even  absent, 
and  there  may  be  no  external  evidence  of  it,  especially  when  the  head  is  firmly 
engaged.     The  claim  that  collapse  after  delivery  means  rupture  of  the  uterus 

is  sound,  but  there  are  cases  in  which  there  is 
extensive  rupture  without  collapse,  and  such 
conditions  are  readily  unrecognized.  Patients 
have  often  experienced  a  sensation  of  tearing, 
and  in  several  instances  have  described  it  to 
me  as  of  "something  giving  way."  The 
hemorrhage  which  nearly  always  occurs  may 
be  external  or  internal.  In  proportion  to  the 
severity  of  the  hemorrhage  will  the  symptoms 
be  grave.  Symptoms  of  peritonitis  come  on 
very  quickly.  Terminations  are:  (i)  cicatri- 
zation and  healing;  (2)  rapid  death  from 
hemorrhage  and  collapse;  (3)  retarded  death 
from  peritonitis  and  septicemia. 

Diagnosis. — When  the  foregoing  symp- 
toms have  made  their  appearance,  physical 
exploration  will  confirm  the  diagnosis,  (i) 
Auscultation  shows  cessation  of  fetal  heart- 
sounds,  as  the  fetus  generally  dies.  (2)  Vag- 
inal palpation  is  normal  as  long  as  the  fetus  is 
still  within  the  uterus,  but  if  it  has  passed 
partly  or  completely  into  the  abdominal 
cavity,  the  presenting  part  is  out  of  reach. 
(3)  Abdominal  palpation:  The  uterus  pre- 
serves its  form  if  the  fetus  remains  in  it.  Pres- 
sure increases  the  pain  at  the  point  of  rupture. 
The  painful  region  may  be  emphysematous. 
If  the  fetus  has  escaped  partly  or  completely 
into  the  abdomen,  there  will  be  two  tumors — 
one  the  fetus,  and  the  other  the  retracted 
uterus.  (4)  Direct  examination  of  the  uterine 
cavity.  The  location  and  extent  of  the  rup- 
ture may  be  discovered  in  this  manner.  Some- 
times there  is  hernia  of  the  intestine  which  be- 
comes strangulated  in  the  uterine  wound.  There  are  cases  of  uterine  rupture 
which  would  have  been  overlooked  if  the  physician  had  not  been  obliged  to  deliver 
artificially.  The  condition  may  be  confounded  with  placenta  praevia  and  acci- 
dental hemorrhage.     (Pages  214  and  224.) 

Prognosis. — This  is  the  most  serious  complication  in  obstetrics ;  the  maternal 
mortality  may  be  placed,  in  complete  rupture,  at  90  per  cent.;  the  fetal  mor- 
tality at  95  per  cent.  Maternal  death  is  due  to  shock,  primary  or  secondary 
hemorrhage,  peritonitis  or  septicemia;  fetal  death  is  due  to  asphyxia  from  inter- 
ference with  the  placental  circulation.     The  foregoing  maternal  mortality  is  esti- 


FiG.  784. — Complete  Rupture  of 
THE  Uterus  Involving  Left  Lat- 
eral AND  Posterior  Walls  and 
Extending  from  the  Contrac- 
tion Ring  almost  to  the  Ex- 
ternal Os,  Which  Latter  is  In- 
tact. Also  complete  rupture  of 
posterior  vaginal  wall  just  below 
external  ring,  opening  into  Doug- 
las's pouch. — {After  a  specimen  in 
the  Museum  of  the  Munich  Frauen- 
klinik.) 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        589 

mated  from  the  unrelieved  cases.  This  is  diminished  under  modem  methods  of 
treatment,  being  placed  at  from  55  to  60  per  cent.  One  reason  for  the  very  un- 
favorable course  of  most  cases  is  that  the  patients  are  already  seriously  weakened 
and  usually  infected  before  the  accident  occurs.  In  incomplete  ruptures  in  which 
the  peritoneal  coat  is  not  torn  the  prognosis  is  naturally  much  more  favorable 
than  in  the  complete,  and  they  occur  more  frequently  than  is  generally  supposed. 
Rupture  may  occur  also  down  to  the  mucosa  from  the  peritoneal  side.  Anterior 
ruptures  may  also  involve  the  bladder,  and  are  therefore  more  serious.  The 
gravity  of  the  case  is  increased  by  complications.  If  the  rectum  or  bladder  is 
lacerated,  there  will  be  an  escape  of  the  contents  into  the  surrounding  tissues. 
There  may  be  hernia  or  incarceration  of  the  intestine  with  subsequent  gangrene. 
There  may  be  rupture  of  an  hematocele,  and  death  from  hemorrhage  or  septic 
peritonitis  may  follow  the  suppuration  of  this  mass. 

Treatment. — Prophylactic  Treatment. — This  is  most  important.  All  cases 
having  obstructed  or  prolonged  labor  from  any  cause  must  be  watched  for 
tetanic  or  cramp-like  action  of  the  uterus,  retraction,  or  dangerous  thinning 
of  the  lower  uterine  segment,  in  order  that  artificial  aid  may  be  given  before  rup- 
ture actually  occurs.  When  rupture  is  threatening,  the  strength  of  the  labor 
pains  must  be  diminished  by  chloroform  or  morphin  and  any  malposition 
of  the  uterus  or  fetus  must  be  corrected.  All  obstetrical  work  must  be  carried 
out  with  the  greatest  caution,  especially  the  application  of  the  forceps.  Some 
cases  will  demand  perforation;  some  in  which  the  presentation  is  a  shoulder, 
may  require  decapitation,  invariably  or  only  when  the  child  is  dead.  Version 
is  usually  attempted  when  the  child  is  alive.  Csesarean  section  may  be  required 
when  rupture  is  threatening  and  delivery  does  not  seem  practicable  by  other 
means.  In  nervous  patients  with  a  tendency  to  tetanic  contraction  of  the 
uterus  the  wise  use  of  anesthetics  will  often  result  in  a  favorable  course.  When 
slight  pelvic  contraction  has  been  diagnosticated,  the  state  of  the  uterus  during 
its  contractions  must  be  carefully  watched ;  and  as  soon  as  the  contraction  ring 
rises,  labor  should  be  quickly  terminated  by  forceps  or  craniotomy.  Decapita- 
tion is  the  only  allowable  method  in  neglected  shoulder  presentation.  In  all 
cases  where  rupture  is  impending,  labor  must  be  ended  by  the  method  safest  to 
the  mother,  regardless  of  the  fetus.  If  the  head  is  immovable,  the  use  of  the 
forceps  is  in  order.  But  if  the  head  is  movable  and  version  contraindicated, 
the  forceps  will  most  likely  injure  both  mother  and  child.  All  violent  manipu- 
lations should  be  avoided.  In  threatened  rupture,  embryotomy  is  preferable  to 
version,  for  the  introduction  of  the  hand  as  well  as  the  turning  of  the  child  is 
very  dangerous  when  the  uterus  is  in  this  condition.  In  cases  of  hydrocephalus 
perforation  is  indicated.  The  chief  complications  which  are  followed  by  danger 
of  rupture  are  contracted  pelvis,  hydrocephalus,  and  shoulder  presentation.  If 
in  neglected  shoulder  presentation  version  is  suggested,  it  should  be  ascertained 
whether  the  fetus  is  still  living.  In  order  to  make  "this  certain  the  hand,  if  pos- 
sible, should  be  passed  up  almost  to  the  shoulder  and  the  cord  palpated  for  pul- 
sations.    Version  is  not  performed  in  case  of  a  dead  fetus. 

Curative  Treatment. — If  rupture  has  already  occurred,  no  disinfecting  douche 
is  to  be  used,  and  the  rupture  must  not  be  allowed  to  increase.  Version  must 
not  be  attempted  in  the  presence  of  a  rupture  with  the  fetus  still  in  the  uterus. 
The  rupture  might  be  made  larger  and  the  perhaps  untom  peritoneum  torn 
through.  If  the  fetus  is  partly  protruding  into  the  abdominal  cavity,  delivery 
is  still  possible  through  the  vagina,  but  it  is  an  uncertain  operation.  Most 
authorities  agree  that  laparatomy  is  the  best  treatment  for  the  majority  of  cases, 
though  Braun  thinks  that  some  can  be  treated  by  uterine  tamponade,  when  the 


590  PATHOLOGICAL   LABOR. 

tear  is  not  too  great,  when  the  placenta  remains  in  the  uterus,  and  when  there 
is  no  sepsis.  I  regard  the  prognosis  as  almost  always  justifying  laparotomy  in 
uterine  rupture.  I  believe  laparotomy  to  be  indicated  in  all  cases  of  complete 
rupture  and  when  there  is  serious  hemorrhage  from  an  incomplete  one.  Sepsis 
is  always  an  indication  for  laparotomy. 

When  celiotomy  is  done  for  a  septic  indication,  the  peritoneum  must  be  pro- 
tected at  all  hazards  from  the  septic  contents  of  the  uterus.  The  operator  is 
next  confronted  with  the  alternative:  Shall  he  save  the  uterus  or  extirpate  it? 
The  indications  for  extirpation,  are  :  (i)  Evidences  of  infection;  (2)  presence  of 
extensive  contusions  and  extravasations  in  the  uterine  wall;  (3)  presence  of  ex- 
tensive laceration  of  the  uterine  supports,  especially  the  broad  ligaments.  If 
these  conditions  are  absent,  the  rent  in  the  uterus  should  be  sutured.  Suture 
of  the  uterus  must  be  done  with  extreme  care,  and  if  the  lips  of  the  wound  are 
Tagged,  contused,  or  necrotic,  they  should  be  resected.  The  sutures  should  in- 
volve only  the  serous  and  muscular  coats  (see  Technique  of  Caesarean  Section, 
Part  X.)  Many  successful  cases  of  suture  have  been  reported.  The  uterine 
tissue  may  be  so  friable  that  suture  of  any  kind  is  out  of  the  question.  Under 
these  circumstances  the  organ  should  be  extirpated.  The  after-treatment  is  like 
that  of  an  ordinary  hysterectomy.  Various  statistics  give  a  mortality  rate  for 
the  operative  treatment  of  uterine  rupture  at  from  25  to  50  per  cent.  Abdominal 
hysterectomy,  if  the  patient  is  in  fair  condition,  in  these  days  of  antiseptic  sur- 
gery is  attended  by  very  good  results. 

Incomplete  ruptures  treated  by  tampon  must  also  be  treated  by  external  ab- 
dominal pressure.  This  method  of  tamponade  is  said  by  some  to  make  possible 
a  subperitoneal  hematoma,  and  pressure  assists  in  preventing  this.  Ruptures 
extending  upward  into  the  supravaginal  portion  of  the  uterus  are  especially  liable 
to  be  accompanied  by  serious  hemorrhage,  from  which  placenta  prsevia  is  to  be 
differentiated.  The  hemorrhage  from  such  lacerations  may  be  very  troublesome 
and  dangerous,  and  it  may  be  necessary  to  open  the  posterior  vaginal  fornix  and 
clamp  the  broad  ligaments  in  much  the  same  way  as  in  a  vaginal  hysterectomy. 

Summary  of  Treatment. — (i)  Curative  treatment  should  always  be  prompt 
and  active;  expectant  treatment  is  usually  fatal  to  the  mother  and  always 
to  the  fetus;  the  fetus  must  be  delivered  by  some  method — podalic  version, 
forceps,  or  craniotomy  if  dead — that  will  cause  as  little  shock  as  possible.  (2) 
A  careful  examination  of  the  position  and  extent  of  rupture  must  be  made. 
(3)  If  the  latter  is  small,  low  down,  posterior,  and  meconium  and  clots  have 
not  escaped  into  the  peritoneal  cavity,  the  uterine  cavity  must  be  freely  irrigated 
with  warm  sterilized  water,  and  a  good-sized  strip  of  sterile  gauze  passed  to  the 
fundus,  a  firm  abdominal  binder  applied,  full  doses  of  ergot  administered,  and 
the  case  treated  expectantly.  One  should  be  prepared  for  laparotomy  on  the 
first  indication  of  peritonitis.  (4)  Large  ruptures  with  escape  of  the  fetus  into 
abdominal  cavity,  and  ruptures  high  up  in  the  uterine  wall,  are  best  treated  by 
removing  the  child  by  the  natural  passages  if  possible  and  immediately  perform- 
ing laparotomy  and  hysterectomy,  or,  instead  of  the  latter,  Sanger's  operation. 

After-treatment. — The  after-treatment  is  upon  general  principles.  If  re- 
covery follows  and  subsequent  pregnancy  occurs,  it  should  be  terminated  at  the 
thirty-sixth  week  to  avoid  spontaneous  rupture. 

VI.  INVERSION  OF  THE  UTERUS. 

Definition. — By  inversion  of  the  uterus  we  mean  a  complete  or  partial 
turning  of  the  uterus  inside  out.     It  may  occur  before  or  after  the  delivery 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT. 


591 


of  the  placenta.  It  is  the  rarest  of  all  complications  of  labor,  occurring  once 
in  200,000  cases,  and  may  be  partial  or  complete.  It  generally  begins  by 
a  slight  depression  of  the  fundus.  In  a  hospital  experience  of  many  thousand 
cases  of  confinement  one  case  of  complete  inversion  has  occurred.  I  have  seen 
in  consultation  practice  several  cases  of  partial  inversion. 

Etiology. — It  is  most  common  in  primiparae  and  is  due  to  the  so-called 
paralysis  of  the  placental  site,  too  vigorous  compression  of  the  fundus,  or  traction 
on  the  cord.  Mismanagement  is  generally  responsible  for  this  complication. 
Other  causes  are  sudden  delivery,  especially  when  the  patient  is  standing 
and  the  uterus  relaxed;  exertion  after  delivery,  such  as  coughing  or  straining; 
heavy  pressure  on  the  fundus  from  above;  or  a  short  cord,  from  whatever  cause. 
The  uterus  must  be  relaxed,  for  inversion  of  a  well- 
contracted  uterus  is  almost  inconceivable.  This 
accident  generally  takes  place  during  the  third  stage 


Fig.  785. — Beginning  Inversion  of  the  Uterus. 


Fig.  786. — Inversion  of  thb 
Uterus. 


of  labor,  although  rarely  it  may  happen  days  after  delivery.  In  very  rare  cases 
it  may  occur  without  reproach  to  the  physician. 

Symptoms. — These  are  acute  pain,  hemorrhage,  and  shock;  imperceptibility 
of  the  fundus  through  the  abdominal  wall  and  a  cup-like  body  in  the  vagina  or 
protruding  through  the  vulva  (Figs.  785,  786).  The  hemorrhage  may  be  slight 
or  profuse  according  to  whether  the  uterine  sinuses  are  closed  or  open.  There  is 
a  rapid,  thready  pulse,  the  skin  is  clammy  and  pale,  and  nausea,  vomiting,  and 
even  syncope  may  occur.  Reflex  cardiac  paralysis  and  cerebral  anemia  may 
result.     Most  rarely  this  complication  may  occur  with  no  apparent  symptoms. 

Diagnosis. — Inversion  may  be  confounded  with  uterine  polyp.  The  latter 
is  insensible  and  does  not  contract  on  examination,  and  its  pedicle  may  be 
traced  upward  through  the  os  uteri  into  the  cavity  and  demonstrated  with 
•a  sound.     The  patient  should   be  catheterized   to  set  aside  the  possibility  of 


592  PATHOLOGICAL  LABOR. 

a  distended  bladder.  If  the  physician  is  present  when  the  accident  occurs, 
and  if  the  placenta  is  wholly  or  partially  attached  to  the  uterus,  the  diagnosis 
is  clear.  The  opening  of  the  tubes  may  be  seen  on  the  lower  part  of  the  tumor. 
The  uterus  is  generally  particularly  sensitive  and  contractile.  An  inverted 
uterus  can  alwaj^-s  be  half  reduced;  polyps  cannot.  Rectal  examination  will 
detect  absence  of  the  uterus  from  its  normal  position. 

Prognosis. — Mortality  is  as  high  as  50  per  cent.  Death,  due  to  either  hemor- 
rhage or  shock,  often  occurs  soon  after  the  accident  (within  half  an  hour).  It  may 
also  be  caused  by  incarceration  of  an  intestinal  loop  in  the  inverted  uterus,  by 
peritonitis,  by  puerperal  infection,  or  by  gangrene.  Cases  are  on  record  in  which 
recovery  has  taken  place  after  the  uterus  has  sloughed.  A  few  cases  in  which 
manual  reposition  was  not  accomplished  were  spontaneously  restored.  The 
prognosis  depends  largely  upon  prompt  reduction  of  the  organ,  as  delay  increases 
the  danger  and  difficulty.     Prognosis  should  always  be  guarded. 

Treatment. — The  accident  can  usually  be  avoided;  hence  the  prophylactic 
treatment  is  most  important.  Precipitate  expulsion  of  the  fetus  should  be 
prevented  and  unnecessary  force  in  Crede's  method  and  in  traction  upon  the 
cord  avoided.  Curative  treatment  consists  in  the  immediate  reduction  of  the 
tumor  with  the  aid  of  anesthesia.  The  bladder  and  rectum  should  be  emptied 
and  reduction  accomplished  by  taxis,  followed  by  intrauterine  irrigation  and  tight 
intrauterine  tamponade.  The  more  quickly  treatment  is  instituted,  the  more 
successful  the  result.  When  the  placenta  is  completely  adherent  or  nearly  so, 
an  attempt  should  be  made  to  replace  it  with  the  uterus,  although  this  is  a  dis- 
puted point.  The  fist  should  be  placed  against  the  inverted  fundus  while  the 
other  hand  makes  counter-pressure  over  the  abdomen.  If  the  placenta  is  almost 
separated  or  if  it  interferes  with  reduction,  it  must  be  entirely  detached.  When 
the  body  of  the  uterus  has  become  swollen  and  congested,  it  is  compressed  either 
manually  or  by  bandaging  before  it  is  reduced.  If  this  is  impossible  on  account 
of  spasmodic  constriction  of  the  os,  anesthesia  may  relax  the  spasm.  Pressure 
firmly  continued  gives  the  best  results.  After  reduction  has  been  accomplished 
the  uterus  must  contract  before  the  hand  is  withdrawn,  and  if  the  placenta 
is  still  attached  it  should  be  separated.  Some  authorities  advise,  in  replacing 
the  uterus,  to  begin  with  that  part  which  was  last  inverted.  In  cases  in  which 
the  uterus  cannot  be  restored  without  great  shock  to  the  patient,  especially 
if  she  is  not  seen  until  several  days  have  elapsed,  the  operation  should  be  delayed 
temporarily.  If  the  uterus  cannot  be  returned,  hemorrhage  can  be  controlled 
by  ergot  and  the  local  application  of  astringents,  such  as  acetic  acid,  and  stimu- 
lating contractions  by  putting  the  child  to  the  breast. 

VII.  EXCESSIVE  RIGHT  LATERAL  OBLIQUITY  OF  THE    UTERUS. 

Although  it  is  a  physiological  fact  that  the  uterus  leans  as  a  rule  to  the 
right  side  in  pregnancy,  this  position  is  sometimes  exaggerated  so  that  much 
of  the  expulsive  power  is  wasted  by  driving  the  presenting  part  against  the 
lateral  pelvic  wall,  resulting  in  delayed  labor,  malpresentations  and  malpositions, 
and  even  in  uterine  rupture  (Fig.  783).  Postural  treatment  by  placing  the 
patient  on  the  left  side  is  usually  sufficient  to  relieve  the  condition. 

VIII.    LACERATIONS    AND    CONTUSIONS  OF   THE    CERVIX,   VAGINA, 

RECTUM,  AND  PERINEUM.* 
I.  Lacerations  and  Contusions  of  the  Cervix. — The  cervix  is  ruptured  very 
frequently  during  labor,  this  accident  invariably  occurring  in  primiparae.     The 

*  Compare  Operations,  Part  X. 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT. 


593 


scars  resulting  from  lacerations  of  the  cervix  constitute  one  of  the  essential 
evidences  of  previous  pregnancy  (Fig.  123). 

Etiology. — The  mere  act  of  labor  itself  is  the  cause  of  the  milder  degrees  of 


Fig.  7S7. 


Fig.  7SS. 


Figs.  787  and  7S8. — Author's  Cases  of  Annular  Detachment  of  the  Cervix.  The 
left-hand  figure  was  in  the  case  of  a  generally  contracted  pelvis,  and  the  other  was 
due  to  incarceration  of  the  anterior  lip  of  the  cervix  between  the  advancing  head 
and  the  symphysis. 


laceration,  the  injury  occurring  during  the  expulsion  of  the  head,  shoulders,  etc. 
Deeper  tears  have  a  different  cause.  There  is  usually  a  predisposition  in  the 
shape  of  organic  rigidity.  Precipitate  or  premature  expulsion  of  the  fetus  before 
dilatation  is  complete  and  operative  extraction  under  the  same  condition  both 
produce  extensive  injuries.  Many 
lacerations  are  due  to  forceps  de- 
liveries and  version,  but  especially 
to  the  unskilful  use  of  instruments. 
Symptoms. — The  vast  majority 
of  tears  are  longitudinal,  involving 
the  OS,  but  circular  lacerations  have 
been  described  (Fig.  789).  In  one 
of  the  author's  cases  of  anatomical 
rigidity  the  entire  portio  was  torn 
from  the  rest  of  the  uterus  (Fig. 
787).  Ordinary  longitudinal  tears 
may  be  single,  bilateral,  or  multiple, 
the  latter  being  rare.  Deep  lacera- 
tions of  the  cervix  may  extend  into 
the  vaginal  culs-de-sac  (extraperito- 
neal rupture  of  the  uterus).  Finally, 
there  is  a  submucous  rupture,  which 
is  manifested  by  a  patulousness  of 
the    OS.       Clinically    the   principal 

symptom  of  ruptured  cervix  is  hemorrhage.  In  the  deeper  varieties  some  of  the 
large  branches  of  the  uterine  artery  may  be  torn.  Cervical  lacerations  often  heal 
spontaneously  during  the  puerperium.  The  diagnosis  is  made  b}^  careful  inspec- 
tion and  palpation.  As  regards  prognosis,  after  the  cessation  of  hemorrhage 
38 


Fig.  789. — Laceration  of  the    Cervix  dur- 
ing Labor. 


594 


PATHOLOGICAL   LABOR. 


m*, 


Fig.  790. — Utero-vesical  Rupture  Due  to  Secon- 
dary Inertia  in  Persistent  Occipito-posterior 
Position.       B,  B' ,  Bladder  ;  R,  rupture. 


there  is  still  danger  of  infection,  and  of  the  development  of  cervical  catarrh, 
with  resulting  tendency  to  abortion. 

Treatment. — The  prophylaxis  consists  in  the  utmost  care  in  all  operative 
procedures  which  involve  either  forcing  or  drawing  the  fetus  through  an  imper- 
fectly dilated  os.  In  regard  to  treatment  proper,  hemorrhage  must  be  arrested 
if  profuse,  and  the  best  method  is  by  immediate  suture  of  the  tear. 

2.  Lacerations  and  Contu- 
sions of  the  Vagina.  (See  Repair 
of  Injuries,  Part  X.) — These  in- 
juries may  be  either  spontan- 
eous or  artificial  in  origin.  The 
lower  third  is  implicated  much 
more  commonly  than  the  rest  of 
the  passage.  Next  in  order 
comes  the  upper  third  (culs-de- 
sac),  and  lastly  the  middle  third. 
Etiology. — Lacerations  of  the 
lower  and  middle  thirds  are  due, 
as  a  rule,  to  the  marked  trans- 
verse distention  of  the  vagina  by 
the  presenting  part.  These  vag- 
inal tears  are  usually  longitu- 
dinal at  the  junction  of  the  pos- 
terior with  one  of  the  lateral 
walls.  Lacerations  of  the  upper 
third  are  due  to  causes  practi- 
cally the  same  as  those  for  rup- 
ture of  the  uterus,  with  which 
they  are  also  clinically  related. 
Submucous  rupture  is  usually 
due  to  the  sudden  descent  of 
the  head  in  precipitate  labors 
and  forceps  extractions.  Many 
lacerations  occur  from  operative 
delivery.  A  special  form  of  in- 
jury to  the  vagina — a  contusion 
rather  than  a  laceration — is  seen 
in  the  upper  third  in  certain  de- 
formities of  the  pelvis  in  which 
bony  projections  encroach  upon 
the  excavation.  Thus  the  ischial 
spines  project  into  the  funnel- 
shaped  pelvis  and  the  crest  of 
the  OS  pubis  in  exostosis  pelvis. 
The  vagina  then  becomes  incar- 
cerated between  the  fetal  head 
and  the  bony  prominence.  Similar  contusions  are  seen  when  the  fetal  head  is 
arrested  in  a  narrow  pelvis,  and  if  the  bladder  is  incarcerated  between  the  fetal 
head  and  the  symphysis  a  vesico -vaginal  fistula  may  result.  (Figs.  790,  791.) 
Ruptures  in  the  upper  third  of  the  vagina  may  originate  from  mere  extension 
of  cervical  lacerations  into  the  culs-de-sac,  or  they  may  begin  in  the  vagina  itself, 
usually  the  posterior  fornix.    These  injuries,  unlike  those  of  the  lower  and  middle 


m 


Fig.   791. — Utero-vesical    Rupture. 
Degree  of  Fig.  790. 


Advanced 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        595 

thirds,  run  chiefly  in  a  transverse  direction.  In  the  most  serious  types  the  vagina 
may  be  torn  across — the  so-called  "colporrhexis."  The  vagina  may  also  be 
separated  from  the  uterus  as  a  result  of  longitudinal  stretching,  which  results 
when  the  uterus  with  the  cervix  is  drawn  upward  over  the  presenting  part.  This 
condition  is  seen  at  times  in  certain  presentations,  such  as  shoulder  or  head  in 
narrow  pelves.  Spontaneous  rupture  of  the  posterior  cul-de-sac  has  been  seen  in 
connection  with  pendulous  abdomen,  congenital  shortening  and  various  acquired 
alterations  in  the  vagina.  Introduction  of  the  hand  into  the  vagina  in  the  per- 
formance of  version  is  a  very  common  cause  of  rupture.  The  same  may  be  said 
of  the  application  of  the  forceps.  Injuries  of  the  anterior  fornix  are  also  almost 
always  artificial. 

Symptoms. — A  peculiar  form  of  laceration  sometimes  occurs  in  which  the 
mucosa  of  the  inferior  vaginal  segment  tears  slightly  while  the  submucous  tissue 
is  extensively  ruptured.  Under  these  conditions  a  pocket  is  formed  in  which  the 
lochial  secretions  may  collect,  with  the  formation  of  abscess  and  fistula.  Lacera- 
tions of  the  middle  and  lower  third  are  accompanied  by  hemorrhage  and  may  be 
followed  by  infection  or  by  the  formation  of  urinary  or  fecal  fistulas.  Hemorrhage 
is  seldom  profuse  unless  the  tears  extend  into  the  paravaginal  tissue.  Lacerations 
of  the  ostium  vaginae  extending  upward  by  the  side  of  the  clitoris  may  provoke 
hemorrhages  which  threaten  life.  In  extensive  injuries,  especially  in  the  "pocket " 
ruptures  already  described,  there  may  be  high  fever,  stagnation  and  putrefaction 
of  lochia,  pelvic  cellulitis,  and  general  infection.  Extensive  injuries  give  rise  to 
cicatricial  stricture  of  the  vagina. 

Diagnosis. — Lacerations  of  the  lower  third  which  are  continuous  with  vulval 
or  perineal  tears  are  diagnosticated  by  stretching  the  ostium  vaginae  with  the 
fingers,  when  the  course  and  extent  of  the  injury  may  be  determined  (Figs.  631 
and  632).  If,  with  vulva  and  perineum  intact  and  uterus  well  contracted, 
arterial  blood  escapes  from  the  vagina,  it' is  evident  that  a  laceration  exists  either 
in  the  cervix  or  in  the  upper  third  of  the  vagina.  The  uterus  should  be  pushed 
into  the  lesser  pelvis  and  drawn  down  with  volsella  forceps.  It  is  common  under 
these  circumstances  to  see  a  deep  laceration  from  the  cervix  into  the  fornix 
vaginas.  Transverse  lacerations  of  the  posterior  cul-de-sac,  which  sometimes 
extend  through  the  peritoneum,  may  be  almost  as  grave  in  their  consequences 
as  rupture  of  the  uterus.  The  clinical  picture  is  much  like  that  of  the  latter,  and 
the  diagnosis  should  be  made  with  the  hand  in  the  vagina. 

Treatment. — Deep  lacerations  recognized  soon  after  delivery  should  be  su- 
tured. If  the  rupture  forms  a  pocket  in  the  submucous  tissue  it  must  be  irri- 
gated with  antiseptics  and  packed  with  gauze.  In  severe  contusions  the  vagina 
must  frequently  be  irrigated  in  such  a  manner  that  the  affected  surface  is  kept 
clear  of  the  lochial  discharge.  If  fistula  form,  they  sometimes  close  spontane- 
ously under  daily  touching  with  nitrate  of  silver. 

3.  Lacerations  of  the  Pelvic  Floor. — These  injuries  comprise  ruptures  of  the 
fourchette,  posterior  vulval  commissure,  perineum,  lower  third  of  the  posterior  and 
lateral  vaginal  walls,  and  the  recto-vaginal  septum.  The  tissues  involved  may 
include  the  integument  from  the  anal  orifice  to  the  posterior  vulval  commissure, 
the  mucous  membrane  of  the  vulva,  vagina,  and  rectum,  the  cellular  tissue, 
the  sphincter  ani  and  levatores  ani  muscles. 

Varieties. — These  lacerations  exhibit  many  varieties  and  may  be  classified 
in  various  ways.  The  arrangement  which  is  taught  in  most  text-books  is,  how- 
ever, only  partially  correct.  It  presents  these  injuries  as  occurring  in  three 
degrees,  as  follows:  The  mildest  grade  of  rupture  extends  from  the  posterior 
vulval  commissure  for  a  variable  distance  into  the  perineal  body;  the  second 


596 


PATHOLOGICAL   LABOR. 


degree  extends  as  far  as  the  sphincter  ani,  while  in  the  highest  degree  the  rupture 
involves  the  sphincter  and  the  recto-vaginal  septum.  This  mode  of  grouping 
takes  no  cognizance  of  lacerations  of  the  vaginal  sulci,  which  are  the  most  fre- 


\ 


Fig.  792. — Abrasions  and  Superficial 
Tears  of  the  Vestibule  and  Vulva. — 
{Redrawn  after  Bar.) 


Fig.  793. — Abrasions  and  Superficial 
Lacerations  of  the  Vestibule  and 
Vulva. — {Redrawn  after  Bar.) 


I 


Fig.  794.  —  Lateral  Vagino-perineal 
Ruptures  with  Abrasions  of  -Sthe 
Vulva. — {Redrawn  after  Bar.) 


Fig.  795. — Perforations  and  Lacera- 
tions of  the  Labia  Minora  and  Vagi- 
nal Inlet. — {Redrawn  after  Bar.) 


MATERNAL  DZSTOCIA   IN   THE  PARTURIENT   TRACT.         597 

quently  occurring  and  the  most  important  of  all  the  accidents,  owing  to  the 
participation  in  the  rupture  of  the  levator  ani  muscle.  Central  rupture  of  the 
perineum  is  described  by  most  authors  as  an  injury  sui  generis,  as  if  it  had  no 
connection  with  the  common  varieties.  It  seems  to  me  that  the  only  way  of 
classifying  and  naming  these  lacerations  is  that  which  takes  Cognizance  of  the 
precise  tissues  involved.  Thus,  ruptures  of  the  pelvic  floor  are  (i)  lacerations, 
(2)  submucous  or  muscular  ruptures. 

(i)  Lacerations  are  (a)  vulval  (fourchette,  posterior  commissure);  (6)  vulvo- 
perineal;  (c)  vaginal  (described  under  that  head);  (d)  intraperineal  (so-called 
central  rupture)  (vagina  also  involved);  (e)  lateral  vagino-perineal  (vulva  in- 
volved), unilateral,  bilateral;  (f)  postero-lateral  vagino-perineal;  (g)  vagino-peri- 
neo-anal  or  rectal;  (h)  perineo-rectal  (extension  of  central  rupture  into  rectum). 
(a)  Vulval:  Abrasions  and  superficial  tears  of  the  vulva  occur  in  most  labors. 
(Fig.  792.)  In  100  consecutive  cases  Auvard  found  81  such  lesions.  In  49 
cases  there  were  accompanying  lacerations  of  the  perineum.  In  32  the  anterior 
and  lateral  parts  of  the  vulva  alone  were  involved.  Tabs  are  frequently  seen 
at  the  sides  of  the  vulva  after  a  difficult  second  stage.  Buttonhole  tears  have 
been  observed  in  the  labia  minora.  In  rare  instances — only  three  or  four  are 
oa  record — the  urethra  has  been  involved.  Most  vulval  lacerations  are  super- 
ficial and  heal  readily  under  antiseptic  treatment.  Lacerations  at  the  side  of 
the  clitoris  may  bleed  profusely.  The  chief  danger,  however,  is  from  sepsis, 
smce  the  vulva,  unlike  the  vagina,  is  the  habitat  of  the  streptococcus  and  other 
pathogenic  germs.  Fourchette:  This  ruptures  in  primiparae  as  a  continuation 
of  rupture  of  the  base  of  the  hymen.  Posterior  commissure:  This  is  torn  by 
extension  of  the  hymen-fourchette  laceration.  Ruptures  of  the  base  of  the 
hymen  and  fourchette  occur  practically  in  all  first  labors  and  are  not  included 
in  the  statistics  of  ruptured  perineum.  (6)  Vulvo-perineal:  In  actual  rupture 
of  the  perineum  the  mildest  degree  must  involve  the  posterior  commissure  and 
extend  for  a  variable  distance  into  the  perineal  body.  (See  Part  X.)  (c)  Vag- 
inal:  Rupture  limited  to  the  lower  third  of  the  posterior  vaginal  wall  is  de- 
scribed under  the  head  of  lacerations  of  the  vagina  {q.  v.).  (Fig.  799.)  {d) 
Intraperineal:  This  is  the  so-called  central  rupture  or  perforation  of  the  peri- 
neum. (Figs.  796  and  797.)  The  posterior  wall  of  the  vagina  is  extensively 
involved.  Very  rarely  the  entire  fetus  passes  through  such  an  opening.  (Fig. 
797.)  It  is  a  rare  accident,  but  75  cases  being  mentioned  in  literature.  These 
ruptures  may  readily  unite,  but  cases  have  occurred  in  which  a  permanent  opening 
has  resulted,  {e)  Lateral  vagino-perineal:  These  represent  a  continuation  of 
vulvo-perineal  ruptures  which  extend  into  the  vaginal  sulci  on  one  or  both 
sides.  (Fig.  794.)  They  are  very  common  and  produce  serious  results  because 
the  fibers  of  the  levator  ani  may  be  included  in  the  rent.  When  both  sulci  are 
involved  a  Y-shaped  lesion  is  produced.  (/)  Postero-lateral  vagino-perineal:  This 
is  the  "  perineal  rupture  of  the  second  degree  "  of  most  authors.  It  extends  to 
the  border  of  the  anus  without  involving  the  latter.  (Fig.  794-)  ig)  Vagino- 
perineo-rectal:  This  is  the  "  rupture  of  the  third  degree,"  or  complete  rupture — 
a  rare  accident.  (See  Part  X.)  As  it  extends  through  the  anus  and  recto- 
vaginal septum,  it  produces  fecal  incontinence.  There  is  little  or  no  attempt 
at  spontaneous  repair,  (h)  Perineo-rectal:  A  very  few  cases  of  intra-perineal 
or  central  rupture  have  extended  into  the  rectum. 

(2)  Submticous  or  muscular  ruptures  were  first  described  by  Schatz.  They 
occur  in  patients  with  unusual  elasticity  of  the  skin  of  the  perineum.  When 
the  latter  is  distended  by  the  advancing  fetus,  the  elastic  integument  readily 
yields,  while  the  more  rigid  muscle  is  ruptured.     (Figs.  798  and  799.) 


598 


PATHOLOGICAL   LABOR. 


Frequency. — It  is  usually  asserted  that  some  injury  to  the  perineum  results 
in  30  per  cent,  of  labors  in  primiparae  and  10  per  cent,  in  multiparae.  Such 
figures  refer  to  maternities,  where  the  prophylaxis  of  these  injuries  is  intelli- 
gently managed.  Doubtless  in  miscellaneous  midwifery  practice,  in  which  the 
attendants  include  numerous  midwives  and  untrained  physicians,  the  figures 
would  be  considerably  higher.  Perineal  lacerations  are  generally  admitted 
to  be  the  most  frequent  of  all  maternal  birth  traumatisms.  In  1200  confine- 
ments at  the  Mothers'  and  Babies'  Hospital,  I  found  that  perineal  lacerations, 
requiring  suture,  occurred  in  88  cases,  or  7.33  per  cent.;  and  in  1000  cases 
at  the  New  York  Maternity,  in  211  cases,  or  21.10  per  cent.     It  is  worthy  of 


',W 


Fig. 


796. — Central  or  Intra-perineal 
Rupture. — {Lepage.) 


Fig.    797. — Central  or   Intra-perineal 
Rupture. —  {Lepage.) 


note  that  in  the  first  series,  with  a  frequency  of  7.33  per  cent.,  nearly  all  the 
1200  cases  were  used  for  clinical  demonstration,  students  delivering  the  patients 
under  the  supervision  of  a  hospital  interne,  while  in  the  second  series,  with 
21.10  per  cent.,  no  clinics  'or  demonstrations  were  held,  nor  were  students 
permitted  to  deliver  the  cases. 

Etiology  and  Mechanism.. — The  predisposing  causes  of  perineal  rupture  include 
unusual  rigidity  of  the  tissues,  seen  especially  in  elderly  primiparae,  corpulence, 
oedema,  and  the  peculiar  friability  of  tissue  seen  in  certain  women.  Exciting 
causes  comprise  rapid  expulsion  in  normal  labors,  whether  delivery  is  spontan- 
eotis  or  artificial.     The  birth  of   the  suboccipito-frontal  circumference  of  the 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT. 


599 


head  is  always  a  menace  to  the  integrity  of  the  perineum  in  cranial  and  breech 
positions,  as  is  the  occipito-mental  in  face  presentation.  The  perineum  is  also 
menaced  by  the  abrupt  expulsion  of  the  posterior  shoulder  in  head  presen- 
tations. The  mechanism  of  traumatisms  of  the  pelvic  floor,  I  believe,  is  as 
follows:  (i)  When  the  remains  of  the  hymen  give  way  to  the  presenting  part 
the  laceration  may  extend  to  the  fourchette,  or,  in  a  multipara,  may  begin  in 
the  latter.  According  to  the  circumstances  in  each  case,  the  injury  may  stop 
at  the  fourchette  or  extend  to  a  variable  degree  into  the  pelvic  floor.  (2) 
The  rupture  of  the  floor  is  simply  a  continuation  of  the  vaginal  laceration.  (3) 
The  mucous  membrane  is  the  first  to  yield,  the  tear  extending  into  the  sub- 
jacent tissue.  Intraperineal  or  central  rupture  occurs,  according  to  Budin, 
in  primiparae  the  residue  of  whose  hymens  is  extraordinarily  unyielding.      In 


Fig.  798. — Lacerations  of  the  Vaginal 
Sulci  and  Submucous  or  Muscular 
Rupture  of  the  Perineum.  The  in- 
tegument over  the  perineum  remains  in- 
tact.— (Redrawn  after  Bar.) 


Fig.  799. — Submucous  or  Muscular  Rup- 
ture of  the  Perineum.  The  integu- 
ment over  the  perineum  remains  intact. 


these  cases  the  distended  posterior  vaginal  wall  ruptures,  involving  the  entire 
perineum  in  the  injury. 

Diagnosis. — This  is  made  by  inspection  and  palpation,  the  parts  being 
put  on  the  stretch  (Figs.  631  and  632). 

Prognosis. — Rupture  of  the  pelvic  floor  is  a  serious  accident,  especially 
when  the  muscles  are  involved.  The  bad  results  may  be  immediate  or  remote. 
The  former  include  the  possibility  of  septic  infection,  which  can  occur  if  the 
recent  wound  is  not  successfully  repaired.  An  infected  lochial  discharge  may 
interfere  with  union  by  second  intention.  The  ultimate  results  of  perineal  tears 
when  extensive  and  unrepaired  are  as  follows:  The  anterior  wall  of  the  vagina 
which  rests  upon  the  intact  perineum  sags  down,  dragging  the  uterus  with  it. 
The  ostium  vaginse  becomes  more  patulous  and  allows  the  posterior  wall  of  the 
vagina  to  prolapse.  Rupture  of  the  levator  muscle  also  causes  sagging  of  the 
pelvic  floor.     Incontinence  of  feces  results  from  rupture  into  the  rectum. 


600  PATHOLOGICAL  LABOR. 

Treatment. — Prophylaxis:  Preservation  of  the  perineum  has  been  placed 
by  some  authorities  as  second  in  importance  only  to  preservation  of  the  lives 
of  the  mother  and  child.  From  this  standpoint  it  is  possible  to  discuss  the 
entire  mechanism  and  conduct  of  labor  with  the  one  aim  in  mind  of  favoring 
the  perineum  under  all  circumstances  when  the  more  weighty  conditions 
do  not  assert  themselves.  This  has  actually  been  done  by  Krantz.*  The 
factors  which  bear  directly  and  indirectly  upon  the  state  of  the  perineum  are 
numerous,  but  for  convenience  we  may  make  three  major  classes:  (i)  Anomalies 
of  the  expiilsive  forces;  (2)  anomalies  of  the  soft  parts, — vagina  and  perineum; 
(3)  faulty  presentations  and  positions  of  the  child. 

Curative  treatment.     (See  Operations,  Part  X.) 


IX.  LABOR  AFTER  OPERATIONS  INVOLVING  THE  GENITALS. 

Pregnancy  and  Labor  after  Ventrofixation  and  Ventrosuspension. — These 
operations  have  now  been  performed  many  hundred  times.  Up  to  1896  at 
least  808  had  been  done  in  America  alone. f  In  this  series  of  cases  at  least 
one  ovary  was  left,  and  pregnancy  followed  in  56  (nearly  7  per  cent.)  of  the 
patients.  The  mortality  in  the  fifty-six  pregnancies  was  less  than  5  per  cent., 
and  but  one  of  the  three  deaths  could  be  attributed  to  the  operation.  The 
percentage  of  pregnancies  terminating  in  abortion  was  7.  In  a  series  of  foreign 
operations  J  comprising  the  results  of  175  pregnancies,  there  were  10  per  cent, 
of  abortions  and  2.25  of  deaths.  It  is  a  matter  for  regret  that  in  these  joint 
statistics  of  231  pregnancies  no  distinction  is  made  between  the  older  and 
more  dangerous  operation  of  fixation  and  the  more  recent  and  safer  ventro- 
suspension. In  the  American  series  of  56  cases  there  were  three  forceps  deliv- 
eries, two  retained  placentae,  and  one  induced  labor,  for  uncontrollable  vomiting. 
Hence,  over  11  per  cent,  of  the  pregnancies  (the  abortions  having  been  sub- 
tracted from  the  total)  were  dystocic.  In  the  series  of  foreign  cases  the 
percentage  of  dystocic  labors  was  exactly  14.  These  percentages  are  of  coiurse 
unfavorable  in  comparison  with  the  results  of  labor  under  ordinary  circum- 
stances, and  therefore  some  authorities  §  advise  a  careful  forecast  of  the  chances 
of  dystocic  births,  and  if  such  are  imminent  they  cotmsel  induction  of  labor 
at  the  eighth  month.  During  the  sixth  month  a  series  of  examinations  shotild 
be  begun  for  the  purpose  of  controlling  the  position  of  the  cervix,  which  may 
be  found  to  be  drawn  up  out  of  the  pelvis  despite  the  apparently  natural 
relations  of  the  fundus.  If  the  cervix  is  thus  displaced,  its  anterior  wall  is 
said  to  constitute  a  tumor  at  the  brim  of  the  pelvis.  According  to  Dickinson,  || 
it  is  by  no  means  easy  to  estimate  the  dimensions  of  this  tumor.  Bidone  ** 
once  forestalled  the  results  of  ventrofixation,  when  delivery  seemed  to  be  im- 
possible, by  performing  laparotomy  and  dividing  the  adhesions  which  crippled 
the  uterus.  Judging  from  the  favorable  termination  of  the  majority  of  cases 
of  pregnancy  following  these  operations,  this  resource  of  Bidone's  is  indicated 
only  under  very  exceptional  circumstances.  As  in  cases  of  obstructive  dystocia 
in  general,  the  issue  most  to  be  dreaded  in  theory  is  rupture  of  the  uterus. 

*  ''  Die  Aetiologie  d.  geb.  Dammverletzung, "  Wiesbaden,  1900. 
t  Gordon:  "Transactions  of  the  American  Gynecological  Society,"  1896. 
X  Noble:   "Transactions  of  the  American  Gynecological  Society,"  1896,  . 
§  "Amer.  Jour,  of  Obstetrics,"  1901,  xliv,  40. 
II  Borland  and  Noble:  "Amer.  Jour,  of  Obstetrics,"  1897,  p.  121. 
**  "Amer.  Jour,  of  Obstetrics,"  1901,  xliv,  40. 


MATERNAL  DYSTOCIA   IN   THE  PARTURIENT   TRACT.        601 

Dickinson,*  who  has  had  one  fatality  from  this  accident  and  who  performed 
Caesarean  section  in  a  subsequent  case  (of  twin  pregnancy),  with  a  second 
fatal  result,  assures  us  that  rupture  of  the  uterus  is  a  rare  termination  of  these 
labors,  and  that  but  eight  Caesarean  sections  are  on  record  in  this  connection. 
In  both  of  Dickinson's  fatal  cases  fixation  of  the  uterus  was  present,  although 


Fig.  800. — Maternal  Dystocia  following  Anterior  Fixation  of  the  Uterus.  Shoulder 
presentation,  in  the  left  scapulo-anterior  position;  buckling  of  the  uterus  upon  itself; 
elongation  of  the  cervical  canal ;  manual  dilatation  of  the  cervix  followed  by  a  difficult 
version  and  extraction,  and  delivery  of  a  dead  fetus. — (Case  seen  by  tlie  author  in 
consultation  with  Dr.  Nathan  G.  Bozentan,  of  New  York.) 


in  the  first  example  the  operator  had  attempted  to  perform  suspension. 
Ventral  fixation  as  pregnancy  advances  may  possibly  result  in  what  is  practically 
a  ventral  suspension,  by  the  constant  dragging  of  the  ever-enlarging  uterus. 
A  more  serious  termination,  however,  is  the  occurrence  of  marked  expansion  of 
the  comua,  and  an  exaggerated  anteflexion  of  the  anterior  uterine  wall.  The 
*  "Amer.  Jour,  of  Obstetrics,"  1901,  xliv,  34. 


602  PATHOLOGICAL   LABOR. 

cervix  is  drawn  upward  and  backward,  even  to  the  sacral  promontory,  and 
an  elongation  or  supravaginal  hypertrophy  of  the  cervical  canal  results  (Fig. 
800).  The  internal  os,  then,  may  be  found  as  high  as  the  second  or  third  lumbar 
vertebra.  I  saw  a  case  of  this  character  in  consultation  with  Dr.  Nathan  G.  Boze- 
man,  of  New  York.  The  patient  was  at  term,  suffering  from  secondary  inertia 
and  exhaustion,  with  a  dead  fetus  in  the  left  scapulo-anterior  position.  After 
a  difficult  dilatation  of  the  elongated  cervical  canal,  I  was  able  to  seize  the 
upper  leg  and  gradually  extract  the  child  around  the  obstruction  formed  by 
the  hypertrophied  cervix  and  thickened  fundus  (Fig.  800). 

Labor  after  Vaginofixation. — Ruhl  *  states  that  severe  interference  with 
labor  may  result  from  the  fixation  of  the  uterus  at  the  anterior  vaginal  wall. 
Nevertheless,  among  hundreds  of  cases  in  which  this  operation  has  been 
performed,  but  9  are  on  record  in  which  labor  had  to  be  terminated  by 
Caesarean  section;  most  of  the  labors  having  been  uneventful.  Ruhl  was  able 
to  supply  notes  of  71  cases  of  vaginofixation  followed  by  pregnancy.  In  3 
cases  it  was  necessary  to  incise  the  anterior  utero-vaginal  wall,  but  in  the  others 
there  were  no  difficulties  attributable  to  the  operation.  Even  in  numerous 
cases  in  which  the  fundus  was  attached  to  the  vagina,  and  in  which  trouble 
might  have  been  expected,  there  were  no  complications  of  labor  except  in 
the  three  cases  just  mentioned.  When  the  fundus  is  sutiu-ed  to  the  vagina 
the  former  is  deeply  placed,  the  cervix  has  a  high  position  and  is  retrodisplaced, 
the  posterior  uterine  wall  is  upon  the  stretch,  and  the  anterior  wall  is  doubled 
upon  itself.  The  fundus  lies  close  above  the  symphysis.  Labor  under  these 
circumstances  pursues  a  peculiar  course.  Slight  uterine  contractions  are 
noted  days  and  even  weeks  before  labor  sets  in,  and  finally  the  os  slowly  dilates. 
In  these  cases  mechanical  dilatation,  as  by  the  use  of  the  colpeurynter,  is  of 
little  benefit  because  of  the  unnattiral  position  of  the  cervix.  After  prolonged 
waiting  the  os  is  sufficiently  dilated  for  the  introduction  of  the  hand,  but  the 
latter  can  enter  only  in  a  cramped  position,  so  that  version,  forceps,  etc.,  are 
hardly  practicable.  Ruhl  on  two  occasions  inserted  his  entire  hand  and  grasped 
a  foot,  but  could  not  deliver  the  child.  In  a  case  in  which  Cesarean  section 
was  performed  the  uterus  was  found  strongly  anteflexed,  literally  standing  on 
its  head,  and  the  posterior  wall  was  stretched  almost  to  the  thinness  of  paper. 


MATERNAL  DYSTOCIA  FROM  OBSTRUCTED  LABOR. 

X.  UTERINE,  OVARIAN,  RENAL,  AND  PERITONEAL  TUMORS. 

General  Considerations. — Tumors  may  produce  either  relative  or  absolute 
obstruction  of  the  birth  canal.  In  the  former  case  the  birth  of  a  living  child 
may  be  possible,  either  unassisted  or  with  the  aid  of  forceps  or  version.  If 
the  presence  of  the  tumor  is  recognized  during  the  course  of  gestation,  extir- 
pation may  be  possible;  or  if  not,  the  pregnancy  may  be  interrupted  or  ar- 
tificial premature  delivery  performed.  If  the  obstruction  to  delivery  is 
absolute  at  term  Csesarean  section  or  perforation  must  be  the  indication. 
While  numerous  forms  of  benign  neoplasms  may  be  present  in  the  pelvis, 
the  vast  majority  are   either  uterine  myomata  or  ovarian  tumors. 

Uterine  Myomata. — The  association  of  these  growths  with  pregnancy  is 
not  of  frequent  occurrence,  perhaps  because  women  thus  afflicted  are  very 
*  "  Monat.  f.  Geburts.  und  Gynak.,"  xiv,  p.  477. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


603 


often  sterile.  Hofmeier  (1900)  shows  that  the  greatest  fecundity  occurs  before 
the  age  of  thirty-five,  while  myomata  tend  to  appear  after  that  period.  When 
a  woman  with  myoma  becomes  gravid,  the  tumor  begins,  as  a  rule,  to  increase 
in  size.  If  it  is  located  within  the  lesser  pelvis,  an  incarceration  of  the  mass 
may  occur,  which  tends  to  produce  a  benign  form  of  degeneration  under  which 
complete  disappearance  may  result.  On  the  other  hand,  the  myoma  may  be 
displaced  upward  with  the  enlargement  of  the  uterus,  a  fact  which  the  physician 
should  turn  to  account  by  a  careful  examination  from  time  to  time.  This  dis- 
placement may  occur  very  late  in  pregnancy,  after  the  operation  of  Cassarean 
section  had  been  decided  upon.  Exceptionally  the  presence  of  these  growths 
may  set  up  peritonitis,  thereby  adding  to  the  difficulties  already  present.  As  a 
rule,  the  presence  of  myoma 
uteri  interferes  little  with  the 
course  of  gestation.  Again, 
if  the  tumors  affect  the  cervix 
rather  than  the  body  of  the 
uterus,  mechanical  disturb- 
ances of  several  kinds  may 
occur,  and  it  is  this  form 
which  tends  to  produce  the 
higher  grades  of  obstructive 
dystocia.  Although,  as  al- 
ready stated,  tumors  in  the 
bony  pelvis  often  ascend  and 
cease  to  obstruct  labor,  even 
after  the  latter  is  under  way, 
this  mobility  appears  to  be 
made  possible  by  a  softening 
which  they  sometimes  under- 
go during  gestation.  After 
delivery  these  tumors  tend 
to  diminish  in  size,  corre- 
sponding to  the  increase 
noted  after  conception.  They 
may  undergo  a  process  of 
complete  involution,  running 
parallel  with  that  of  the 
uterus  itself.  The  presence 
of  myomata  during  the  third 
stage  of  labor  interferes  with 
the  detachment  and  expul- 
sion of  the  placenta,  thereby  favoring  the  occurrence  of  post-partum  hemor- 
rhage. Uterine  myomata  may  undergo  suppuration  during  the  puerperal  period, 
becoming  foci  of  local  sepsis. 

Diagnosis. — The  condition  may  lead  to  several  difficulties  of  diagnosis. 
Thus,  the  metrorrhagia  from  the  presence  of  the  tumor  masks  the  amenorrhea 
of  gestation;  the  enlargement  of  the  uterus  occurs  as  the  result  of  either  con- 
dition. As  pregnancy  advances  the  tumor  may  soften  to  a  remarkable  degree 
and  thus  be  overlooked;  if  a  diagnosis  of  myoma  has  already  been  suggested, 
this  seeming  disappearance  may  lead  to  a  change  of  opinion. 

Prognosis. — This  depends  entirely  upon  the  size  and  seat  of  the  tumor. 
Small  subserous  or  interstitial  tumors  may  be  ignored  in  prognosis  and  treat- 


FlG.  801. 


Myoma  of  the  Lower  Segment  and  Cer- 
vix. 


604 


PATHOLOGICAL   LABOR. 


ment.  Others  ma}^  or  may  not  require  extirpation  during  pregnancy.  As  a 
rule,  gestation  itself  is  undisturbed  by  the  presence  of  the  growths.  Labor  and 
the  puerperium  may  not  be  interfered  with. 

Treatment. — During  pregnancy  the  management  is  as  follows:  If  the  size  and 
seat  of  the  tumor  occasion  apprehension  for  the  welfare  of  the  mother  and  child, 
it  is  better  to  perform  myomectomy,  than  to  interrupt  pregnancy,  for  this  inter- 
ruption destroys  the  child,  is  dangerous  to  the  mother,  and  is  without  effect  upon 
the  tumor.  The  danger  of  accidentally  inducing  abortion  through  the  oper- 
ation of  myomectomy  is  slight.  If  this  operation  is  impracticable,  supra- vaginal 
amputation  of  the  pregnant  uterus  should  be  performed.  Growths  which 
are  dangerous  chiefly  from  their  position  in  the  lesser  pelvis  should  be  watched 
carefully  in  the  hope  that  they  may  ascend.  We  should  even  refuse  to  inter- 
fere at  term,  since  this  ascent  often  occurs  after  labor  has  begun.  Then,  if  ascent 
has  not  occurred  spontaneously,  the  patient  should  be  anesthetized  and  placed 

in  the  lateral,  abdominal,  or 
knee-elbow  position,  when 
it  will  often  be  possible  to 
press  the  mass  into  the  ab- 
dominal cavity,  even  when 
it  appears  to  be  incarcerated 
in  the  pelvis.  If  the  tumor 
is  irreducible,  it  is  better  to 
perform  Caesarean  section, 
even  if  the  child  is  dead, 
because  of  the  great  diffi- 
culty in  perforating  and  ex- 
tracting in  the  presence  of 
the  growth  in  the  pelvis. 

Ovarian  Tumors. — T  h  e 
presence  of  these  neoplasms 
in  the  abdominal  cavity 
adds  to  the  pressure  symp- 
toms caused  by  the  pregnant 
uterus,  and  during  labor  in- 
terferes with  the  force  of  the 
uterine  contractions.  In 
cases  in  which  they  remain 
in  the  pelvis  they  may  cause  either  partial  or  complete  obstruction  of  the 
birth  tract.  Diagnosis:  The  under  surface  of  the  tumor  may  be  made 
out  by  the  vaginal  touch.  If  fluctuation  cannot  be  recognized,  an  explora- 
tory puncture  may  be  made.  As  a  rule,  the  cervix  is  placed  very  high,  and 
the  presenting  part  of  the  child  does  not  descend.  Course  and  Prognosis:  The 
complication  of  ovarian  tumor  with  pregnancy  is  always  serious.  The  cyst  is 
liable  to  rupture,  which  event  might  be  regarded  as  desirable  except  for  the 
danger  of  peritonitis,  hemorrhage,  and  gangrene  of  the  cyst.  Treatment:  Such 
cases  should  never  be  left  to  Nature.  If  the  tumor  is  recognized  during  preg- 
nancy, it  must  be  extirpated  unless  very  small.  The  same  course  is  advised 
even  during  labor,  whenever  practicable.  Thus,  in  a  typical  case  the  indication 
would  be  to  perform  laparotomy,  extirpate  the  growth,  and  terminate  the  labor 
by  Caesarean  section.  This  course  cannot  be  pursued  as  a  matter  of  routine, 
and  in  the  majority  of  cases  the  operator  has  to  be  content  with  the  attempt 
to  push  the  tumor  from  the  pelvis  into  the  abdominal  cavity.     He  must  be 


V, 


Fig.  802. — Myoma  of  the  Cervix  which  Has  Been 
Pushed  Down  into  the  Vagina  by  the  Advancing 
Head.    Face  Presentation,    Left  Mento-anterior. 


MATERNAL   DYSTOCIA    FROM    OBSTRUCTED   LABOR.  605 

prepared  in  these  cases  for  the  accidental  rupture  of  the  cyst ;  and  if  the  attempts 
at  reposition  fail,  he  should  seek  to  diminish  the  size  of  the  mass  by  tapping. 
If  this  resource  also  fails,  and  if  the  exigency  of  the  case  forbids  extirpation  of 
the  growth,  Cassarean  section  alone  must  be  performed. 

Miscellaneous  New  Formations. — Other  benign  tumors  which  may  cause  ma- 
ternal dystocia  are  of  rare  occurrence.  They  comprise  dermoids  of  the  pelvic 
connective  tissue;  echinococci  in  the  same  location  and  also  in  the  peritoneal 
cavity;  floating  kidney  and  spleen,  etc.  As  a  rule,  the  various  cystic  formations 
should  be  treated  like  ovarian  tumors.  Displaced  organs  should  be  replaced 
before  delivery,  or  if  they  complicate  labor  they  should  be  thrust  out  of  the 
way.  Hernias — umbilical,  inguinal,  femoral — may  form  an  obstacle  to  labor 
by  interfering  with  the  proper  force  of  intra-abdominal  pressure.  They  should 
be  reduced  or  held  in  position  until  after  the  delivery  has  been  effected,  when, 
if  necessary,  they  may  receive  attention. 


XI.  ANOMALIES  OF  THE  MEMBRANES. 

The  dystocic  element  in  force  here  is  connected  principally  with  the  period 
of  rupture,  and  hence  we  may  consider  the  entire  subject  under  the  following 
classification:  (i)  Dystocia  from  premature  rupture;  (2)  dystocia  from  tardy 
rupture;  (3)  dystocia  from  adherent  membranes. 

1.  Premature  Rupture. — Premature  rupture  is  not  necessarily  due  to  any 
intrinsic  peculiarity  of  the  membranes,  but  to  anomalous  conditions  elsewhere; 
i.  e. ,  contracted  pelvis,  or  shoulder  presentation.  A  certain  proportion  is  thought 
to  be  of  endometritic  origin.  Early  rupture  of  the  membranes  is  of  frequent 
occurrence,  but  the  condition  is  not  invariably  dystocic  because  the  amniotic 
fluid  does  not  necessarily  all  escape.  When  such  is  the  case,  however,  the 
dystocic  condition  known  as  "dry  labor  "  develops.  (Page  570.)  The  loss  of 
the  water  wedge  before  the  completion  of  dilatation  brings  the  head  of  the 
fetus  in  direct  contact  with  the  cervix;  this  tends  to  induce  a  tetanic  action 
of  the  uterus  and  work  injury  to  the  cervix.  The  latter  becomes  greatly 
elongated  and  its  anterior  lip  often  oedematous;  laceration  is  very  common. 
Compression  of  the  fetal  head  causes  a  tendency  to  asphyxia  and  intracranial 
hemorrhage.  The  tetanic  action  of  the  uterus  combined  with  the  oedematous 
cervix  retards  the  first  stage  of  labor  and  exhausts  the  mother.  Premature 
rupture  is  greatly  dreaded  in  anomalous  presentations  and  contracted  pelves, 
conditions  under  which  it  is  especially  prone  to  occur.  In  such  cases  it  con- 
tributes a  further  element  of  dystocia.  The  form  of  irregular  uterine  action 
caused  by  dry  birth  is  described  under  anomalies  of  the  expulsive  forces  (page 
570);  the  injuries  of  the  cervix  are  given  on  page  592,  and  the  treatment  comes 
tinder  the  head  of  protracted  first  stage.     (Page  572.) 

2.  Tardy  Rupture. — Dystocia  connected  with  tardy  rupture  of  membranes 
originates  in  anomalies  of  the  membranes  themselves,  such  as  increased  density 
or  elasticity.  After  full  dilatation  there  is  no  tendency  to  spontaneous  rupture, 
engagement  goes  on,  and  rupture  may  occur  in  the  vagina  or  the  fetus  may 
be  bom  with  its  membranes  intact  ("bom  with  a  caul  ")  (Fig.  1009).  Dystocia 
in  these  cases  comes  from  the  additional  work  thrown  upon  the  uterus  by 
having  to  expel  the  unyielding  amniotic  fluid  along  with  the  fetus.  This  con- 
dition is  remedied  by  simply  puncturing  the  membranes  as  soon  as  dilatation 
is  complete. 

3.  Adhesions. — Another  form  of  dvstocia  of   membranous  origin  is  due  to 


606  PATHOLOGICAL   LABOR. 

adhesions  between  the  membranes  and  the  lower  segment  of  the  uterus.  The 
cause  is  endometritis.  When  labor  begins,  the  cervix  fails  to  dilate  and  the 
condition  may  be  confounded  with  agglutination,  inertia,  rigid  os,  etc.  The 
cervix  is  pervious  to  the  finger  and  the  adhesions  may  be  plainly  felt.  Although 
the  uterine  body  may  be  contracting  readily,  the  cervix  remains  passive.  After 
a  variable  period  the  chorion  gives  way  and  dilatation  begins  with  the  amnion 
as  the  sole  membrane  of  the  bag  of  waters.  In  some  cases  the  chorion  does 
not  give  way  of  itself;  it  must  then  be  detached  by  sweeping  the  finger  around 
the  inner  os.  (Page  573.)  If  this  attempt  fails,  it  is  justifiable  to  puncture 
the  bag  of  waters  even  if  dilatation  has  not  occurred,  as  the  os  will  then 
dilate. 


XII.  RIGIDITY  OF  THE  INTERNAL  AND  EXTERNAL  OS.     TRISMUS 

UTERI. 

Numerous  states  of  the  cervix  may  be  responsible  for  its  failure  to  dilate 
during  the  first  stage  of  labor.  The  various  conditions  which  determine  dystocia 
of  cervical  origin  should  be  considered  together,  even  at  the  risk  of  repetition, 
especially  in  regard  to  differential  diagnosis,  although  some  of  them  are  not 
entitled  to  the  designation  of  rigid  os  or  cervix.  The  causes  of  cervical  dys- 
tocia may  be  divided  into  (i)  functional,  (2)  organic. 

1.  Functional  or  Spastic  Rigidity.  Trismus  Uteri. — Dystocia  of  functional 
origin  is  due  principally  to  a  spastic  rigidity  of  ike  external  os;  much  more  rarely, 
and  usually  in  premature  births,  we  observe  a  corresponding  condition  in  the 
internal  os,  more  pronounced  in  induced  than  in  spontaneous  delivery.  The 
extreme  type  of  spastic  rigidity  is  known  as  "trismus  uteri."  Dystocia  of  func- 
tional character  is  very  common,  its  frequency  being  due  to  the  great  variety  of 
conditions  under  which  it  occurs.  Etiology:  The  most  pronounced  type  is  the 
reflex.  Some  conditions  on  which  this  depends  are  (i)  the  immediate  pressure  of 
the  fetal  head  on  the  cervix  in  premature  rupture  of  the  membranes  with  evacu- 
ation of  the  amniotic  fluid;  (2)  the  presence  of  a  malposition  of  the  fetus  with 
failure  of  the  presenting  part  to  adapt  itself  to  the  cervix,  the  membranes  having 
prematurely  ruptured;  (3)  pre-existent  inflammatory  conditions  of  the  lower  seg- 
ment; (4)  ill-advised  attempts  at  operative  interference;  (5)  any  condition  of  the 
upper  segment  which  can  induce  painful  contractions ;  (6)  distended  bladder  and 
rectum.  Spasm  of  the  internal  os  is  a  condition  evidently  little  understood.  Recent 
experience  has  taught  me  that  functional  rigidity  is  often  present  at  the  internal 
OS  in  late  abortions  and  premature  labors.  Often  both  internal  and  external  rings, 
as  well  as  the  lower  part  of  the  uterus  are  involved.  In  addition  to  essential 
functional  rigidity,  it  is  highly  probable  that  in  the  organic  forms  about  to  be 
described  more  or  less  functional  spasm  coexists.  A  species  of  rigidity  which 
appears  to  be  sui  generis  is  that  which  occurs  in  elderly  primiparae.  It  has  been 
termed  "organic,"  "fimctional,"  and  both  combined.  It  has  been  proposed  to 
distinguish  this  form  by  the  names  "constitutional"  or  "anatomical." 

2.  Organic  Rigidity. — The  numerous  conditions  which  have  been  comprised 
under  this  head  are  divisible  into  two  classes,  (i)  congenital  and  (2)  acquired, 
(i)  Congenital:  Complete  imperforation  would  prevent  all  chance  of  conception. 
Congenital  elongation  of  the  portio  is  practically  the  only  known  congenital  mal- 
formation of  the  OS  from  the  standpoint  of  cervical  dystocia.  This  condition  has 
been  known  to  delay  the  first  stage  of  labor  and  to  require  mechanical  dilatation. 
(2)  Acquired:  These  may  be  divided  into  four  classes :  (i)  Conditions  which  alter 
the  consistency  of  the  cervix;  (2)  conditions  which  efface  the  os;  (3)  deviations  of 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR.  607 

the  cervix ;  and  (4)  adhesions  between  the  cervix  and  membranes.  The  three  last 
named  have  all  been  described  elsewhere  (pages  603,  608,  605).  There  remains  for 
consideration  acquired  organic  rigidity  in  the  narrower  sense  of  the  term.  Of  this 
there  are  six  varieties:  (i)  Traumatic  or  cicatricial.  These  are  caused  by  opera- 
tion or  the  use  of  the  cautery.  Authorities  differ  as  to  the  ability  of  the  ordinary 
tears  of  childbirth  to  produce  this  condition.  Sloughing  of  the  cervix  should  be 
followed  by  changes  of  this  character.  The  parts  are  the  seat  of  more  or  less 
scar  tissue,  while  the  cervical  canal  may  contain  bridles  of  the  same.  (2) 
The  hypertrophic  conical  elongation  of  the  cervix  as  seen  in  prolapse  of  the 
genitals.  Such  a  cervix  dilates  slowly,  but  there  is  no  further  abnormality. 
(3)  Inflammatory.  More  or  less  rigidity  may  result  from  cervical  endometritis 
and  metritis  if  severe  or  protracted.  (4)  Specific.  Tamier  devotes  consider- 
able attention  to  syphilitic  rigidity  of  the  cervix  which  may  occur  in  a  variety 
of  forms — the  induration  of  a  primary  sore,  the  sclerosis  which  follows  upon 
the  unnatural  development  of  the  mucous  patches  in  connection  with  that 
of  the  pregnant  uterus;  gummata;  tertiary  ulcers;  cicatrization,  and,  finally, 
a  peculiar  type  of  sclerosis  comparable  to  syphilitic  stricture  of  the  rectum, 
in  which,  as  is  well  known,  the  lesions  are  non-specific,  although  the  cause 
is  clearly  syphilitic  (parasyphilitic  sclerosis).  (5)  Neoplastic.  Benign  tumors 
of  the  cervix  have  been  considered  elsewhere.  (6)  Malignant.  (See  Cancer 
of  the  Uterus,  page  610.) 

The  symptoms,  diagnosis,  and  management  of  the  foregoing  may  be  con- 
sidered in  common. 

Symptoms. — The  os  dilates  slightly  or  not  at  all,  so  that  labor  cannot  advance. 
If  dilatation  is  possible,  the  process  is  very  slow.  The  condition  becomes  one 
of  obstructed  labor  in  the  first  stage  and  the  subject  is  treated  under  that  head 
(page  570).     Individual  symptoms  will  be  mentioned  under  diagnosis. 

Diagnosis. — Spasmodic  rigidity  theoretically  should  readily  be  distinguished 
from  any  other  form,  but  as  a  matter  of  fact  spasm  may  be  associated  with  organic 
rigidity,  so  that  the  presence  of  the  latter  is  not  excluded.  Some  authorities 
recognize  the  presence  of  spasm  in  slow  dilatation,  by  the  absence  of  tension  in  the 
bag  of  waters,  and  of  the  normal  mucus  of  the  cervix  (Galabin),  by  its  tender- 
ness and  heat,  and  by  the  hard,  thin,  unyielding  edge  of  the  cervix  (Tamier). 
When  a  physician  is  confronted  by  non-dilatation,  he  should  exclude  all  possi- 
bility of  such  conditions  as  deviation  and  occlusion  and  of  adhesions  between  cer- 
vix and  membranes.  He  then  has  to  distinguish  between  (i)  functional,  and  (2) 
organic  rigidity.  Owing  to  differences  in  the  conception  of  these  conditions  by 
different  authorities,  it  is  hardly  possible  to  lay  down  rules  for  diagnosis  which 
will  be  in  harmony  with  the  teachings  of  all.  I  believe  it  is  of  vital  importance 
to  distinguish  between  mere  slowness  of  dilatation  and  organic  rigidity,  etc. ;  in 
other  words,  between  cases  for  intervention  and  for  non-intervention. 

Treatment. — Spastic  rigidity:  The  tendency  of  this  condition  is  gradually  to 
disappear;  dilatation  being  finally  established.  Serious  accidents  are  rare.  A 
certain  amount  of  expectancy  is  indicated  in  conjunction  with  antispasmodics, 
including  warm  vaginal  irrigations,  chloral  or  opiates  by  the  rectum,  and,  if 
the  preceding  fail,  the  inhalation  of  chloroform.  Finally,  if  everything  has 
failed,  spasmodic  ridigity  must  be  treated  like  other  forms  by  hydrostatic  manual 
or  instrumental  dilatation  and  multiple  incisions.  The  preceding  summary  of 
treatment  does  not  include  any  causal  indications;  it  is,  of  course,  understood 
that  causal  elements,  if  amenable  to  removal,  will  be  so  dealt  with  before  other 
treatment  is  instituted.  If  the  causes  cannot  be  reached,  the  symptom  must 
be  treated  directly  as  above.     Congenital  organic  rigidity:  After  a  due  interval  of 


608 


PATHOLOGICAL   LABOR. 


expectancy,  say  four  or  five  hours,  artificial  dilatation  should  be  begun  with  the 
finger  or  instrumental  dilators  and  finished  with  the  use  of  the  hydrostatic  bag 
or  by  bimanual  dilatation.  (See  Operations,  Part  X.)  Acquired  organic  rigidity. 
There  is  a  likelihood  that  all  these  forms  of  organic  rigidity  will  be  accompanied  by 
a  certain  amount  of  functional  spasm,  hence  some  good  might  be  accomplished 

by  applying  the  treatment  already 
indicated  for  spastic  rigidity  while 
awaiting  dilatation.  When  inter- 
vention is  proved  to  be  necessary, 
dilatation  should  be  attempted; 
Ervix.  and  if  this  fails,  incisions  are  indi- 
cated.    (See  Operations,  Part  X.) 


XIII.  DEVIATION    OR    MALPO- 
SITION OF  THE  CERVIX. 

In  this  condition  the  cervix  may 
occupy  either  the  anterior  or  poste- 
rior fornix  or  may  be  displaced 
laterally  after  the  same  fashion 
(Figs.  803  and  804).  Etiology: 
The  common  but  not  sole  cause  of 
this  condition  is  obliquity  of  the 
entire  uterus.  The  same  effect  is 
produced,  however,  by  overdevel- 
opment of  some  portion  of  the 
inferior  segment  during  the  latter 
part  of  pregnancy.  These  may 
both  coexist  in  the  same  uterus. 
Backward  deviation  is  the  more 
frequent  clinical  variety  (Fig.  803). 
It  is  due  either  to  anteversion  or  to 
overdevelopment  of  the  anterior 
portion  of  the  lower  segment.* 
This  form  of  deviation  is  very 
common  (Fig.  803).  Anterior  and 
lateral  deviations  are  produced  in 
a  similar  manner,  but  are  of  -much 
more  rare  occurrence  (Fig.  804). 
Symptoms :  As  in  all  dystocic 
anomalies  of  the  cervix,  most  of 
our  information  is  obtained  from 
touch,  confirmed  in  certain  cases 
by  the  result  of  palpation  of  the 
uterus  through  the  abdominal  wall. 
^The  vaginal  touch,  which  should 
always  take  account  of  the  culs-de-sac,  finds  one  effaced  and  the  other  of  undue 
depth.  In  backward  deviation  the  fetal  head  is  often  found  engaged  and  almost 
upon  the  pelvic  floor.  The  cervix  looks  directly  backward  upon  the  sacrum,  at 
a  height  which  varies  in  individual  cases,  and  which  may  attain  the  promontory. 

*  Sacciform  dilatation  of  the.  anterior  portion  of  the  lower  uterine  segment. 


Fig.  803. — Backward  Deviation  or  Malposi- 
tion OF  THE  Os.  Sacciform  dilatation  of  the 
anterior  portion  of  the  lower  uterine  segment. 
Of  frequent  occurrence. 


CetvIk 


Fig.  804. — Anterior    Deviation   or    Malposi 
TiON  of  the  Os.     a  Rare  Anomaly. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR.  609 

It  may  be  difficult  in  the  latter  case  to  feel  the  os  at  all  (Fig.  803).  In  anterior 
deviation  the  conditions  are  reversed.  The  os  looks  toward  the  upper  part  of  the 
symphysis,  and  it  may  be  impossible  to  reach  it  with  the  finger,  unless  the 
patient  is  first  placed  in  the  genupectoral  position.  (See  Posture,  Part  X.) 
Analogous  symptoms  are  present  in  lateral  deviation.  Diagnosis  :  If  the  prac- 
titioner cannot  locate  the  os,  he  may  conclude  erroneously  that  he  is  dealing 
with  imperforation  of  the  cervix,  or  that  the  latter  has  become  completely 
effaced  by  dilatation.  It  has  happened  that  the  inexperienced  have  sought  to 
apply  forceps  under  the  latter  misapprehension.  In  order  to  make  a  differential 
diagnosis  it  is  sometimes  justifiable  to  rupture  the  membranes.  I  urge  that  the 
patient  be  chloroformed  and  a  manual  exploration  made.  Prognosis  :  Generally 
deviations  give  an  unfavorable  prognosis,  which  varies  with  the  degree  of  the 
complication.  In  the  milder  cases  spontaneous  restitution  may  occur  as  labor 
advances.  In  the  more  severe  types  all  the  phenomena  of  obstructed  labor  may 
be  developed.  Treatment :  After  a  period  of  waiting  for  nature  to  correct  the 
deviation,  an  attempt  should  be  made  to  tilt  the  cervix  into  its  proper  axis  by 
the  finger  in  the  vagina  and  hooked  into  the  os,  choosing  the  time  when  a 
pain  is  present.  If  this  succeeds,  the  position  of  the  cervix  should  be  tested 
during  subsequent  pains.  If  it  fails,  as  is  frequently  the  case  in  anterior  devia- 
tion, it  may  be  necessary  to  open  the  os  mechanically  and  to  extract  the  child, 
alive  or  dead. 


XIV.    OCCLUSION    OF    THE    EXTERNAL  OS. 

This  condition — also  known  as  conglutination,  agglutination,  or  obliteration 
of  the  external  os — can  occur  only  after  impregnation  has  taken  place.  How- 
ever, there  is  probably  an  incomplete  degree  of  this  condition  which  might 
permit  the  entrance  of  spermatozoids  into  the  uterus.  Etiology  :  Occlusion  of 
the  OS  comprises  several  types.  In  the  simplest  form  the  os  is  agglutinated 
with  inspissated  mucus.  A  more  complex  variety  represents  obliteration  from 
fibrous  adhesions.  The  actual  cause  of  occlusion,  or  at  least  of  the  type  of 
fibrous  adhesion,  is  traumatism,  the  healing  of  old  lacerations,  the  results  of  cau- 
terization or  inflammation.  A  predisposition  may  be  present,  such  as  congenital 
narrowing  of  the  cervix.  Occlusion  occurs  more  frequently  in  multigravidae. 
Symptoms  and  Diagnosis  :  There  are  hardly  any  symptoms  in  the  ordinary  sense 
of  the  word.  The  imperforate  condition  is  recognized  at  the  onset  of  labor, 
and  has  then  been  mistaken  for  complete  dilatation.  The  closed  os  is  some- 
times recognized  and  located  by  the  presence  of  a  slight  prominence  or  depression. 
A  valuable  symptom  is  the  dryness  of  the  vagina  from  the  absence  of  cervical 
secretion.  Diagnosis  can  be  made  only  after  rigidl}^  excluding  other  dystocic 
anomalies  of  the  cervix.  It  is  often  impossible  to  distinguish  between  the  two 
principal  forms  of  obliteration.  Prognosis  :  The  os  may  open  spontaneously, 
especially  in  the  mucus  agglutination;  otherwise  we  may  look  forward  to  the 
various  phenomena  of  obstructed  labor.  Treatment :  The  closed  os  must  be 
reopened,  if  possible,  by  the  finger,  using  the  nail.  This  is  eas}^  with  mucus  agglu- 
tination or  incomplete  fibrous  occlusion.  In  two  cases  of  complete  occlusion 
I  have  reopened  the  os  with  blunt  scissors  during  labor.  In  one  case  it  was 
necessary  to  dilate  the  opening  manually.  In  the  higher  degrees  of  the  fibrous 
type  it  may  be  necessary  to  perform  vaginal  Csesarean  section.  (See  Operations, 
Part  X.)  In  intermediate  grades  it  may  suffice  to  incise  the  site  of  the  os  in 
different  directions  with  the  scissors  or  bistoury  and  to  apply  the  forceps. 

39 


610  PATHOLOGICAL   LABOR. 


XV.    CANCER    OF   THE  UTERUS. 

As  a  general  rule,  if  a  woman  with  uterine  cancer  becomes  pregnant,  the 
disease  is  aggravated.  In  some  15  per  cent,  of  cases  the  pregnancies  are  inter- 
rupted, and  in  the  remainder  at  least  a  third  of  the  children  are  still-born  even 
at  term,  the  proportion  being  much  larger  in  premature  delivery.  Prolonged 
pregnancy  is  not  uncommon  in  women  with  uterine  cancer.  Spontaneous 
delivery  is  possible  when  much  of  the  cervix  remains  intact,  and  even  when  it 
is  largely  replaced  by  cancerous  tissue,  provided  the  latter  is  yielding.  The 
softening  of  the  affected  tissue,  however  pernicious  in  itself,  may  enable  the 
uterus  to  expel  its  contents.  If  the  fetus  cannot  pass  the  obstruction  a  delayed 
labor  results,  and  cases  are  on  record  in  which  the  women  thus  afflicted  have 
been  in  labor  for  over  a  week.  Under  these  circumstances  maternal  death  from 
exhaustion,  or  death  and  putrefaction  of  the  fetus,  or  general  maternal  septi- 
cemia may  occur.  Another  possibility  is  rupture  of  the  uterus.  If  delivery 
results  without  the  occurrence  of  these  accidents,  the  patient  is  doomed  to  pass 
into  the  cancerous  cachexia.  The  recognition  of  cancer  of  the  uterus  should 
not  be  difficult.  If  some  doubt  exists,  a  piece  of  the  cervix  should  be  excised 
and  examined  microscopically.  The  presence  of  cancer  sometimes  obscures 
the  diagnosis  of  early  pregnancy.  Treatment :  If  the  patient  is  seen  during  the 
course  of  the  pregnancy,  an  attempt  may  be  made  to  let  the  case  go  on  to  term, 
and  treat  the  woman  with  anodynes,  hemostatics,  tonics,  etc.  Such  a  course 
should  be  elected  only  at  the  request  of  the  patient  and  under  peculiar  circum- 
stances, such  as  the  desire  for  an  heir.  To  extend  this  line  of  treatment  it  would 
also  be  rational  to  perform  a  palliative  operation  upon  the  cancer.  In  the 
majority  of  cases  the  natural  course  to  pursue  would  be  to  interrupt  the  preg- 
nancy after  the  child  becomes  viable,  or  to  perform  a  Caesarean  or  Porro-Caesarean 
operation,  or  hysterectomy.  Therapeutic  abortion  is  strictly  contraindicated 
in  these  cases.  (See  Part  X.)  These  radical  measures,  however,  are  not  always 
indicated  or  applicable,  and  if  the  obstetrician  finds  himself  in  the  presence  of 
a  case  of  labor  in  a  woman  with  uterine  cancer,  when  the  immediate  indication 
is  to  oppose  the  rigidity  of  the  os,  the  proper  course  to  pursue  is  mechanical 
dilatation  or  incision,  the  latter  being  full  of  danger  to  the  patient.  As  these 
measures  may  be  insufficient,  it  is  permitted  to  perform  a  rapid  ablation  of  the 
cancerous  cervix  and  to  deliver  the  child  with  the  aid  of  the  forceps  or  ver- 
sion ;  or  in  case  of  death  of  the  fetus,  some  form  of  embryotomy  is  the  indication. 
Caesarean  section  alone  is  the  indication  of  necessity  when  the  cancer  has  ex- 
tended from  the  uterus  to  the  vagina  or  has  become  inoperable.  A  total 
hysterectomy  should  be   performed  when  the  cancer  is  technically  operable. 


XVI.    RIGIDITY   AND   ATRESIA    OF   VAGINA    AND    VULVA. 

Obstruction  to  labor  arising  within  the  vagina  may  be  either  (i)  functional 
or  (2)  structural.  The  former  consists  in  the  spasmodic  condition  known  as 
vaginismus. 

I.  Vaginismus. — Vaginismus  is  almost  peculiar  to  first  labors.  If  it  is  of 
high  degree,  the  first  indication  is  to  resort  to  chloroform  narcosis.  If  by  this 
means  the  spasm  is  not  overcome,  then  manual  dilatation  or  deep  incision  should 
be  practised,  with  subsequent  application  of  the  forceps  in  obstinate  cases.  The 
spasmodic  condition  of  the  pelvic  floor  may  attain  such  a  high  degree  that 
delivery  of  a  living  child  is  impossible. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR.  611 

2.  There  are  a  number  of  structural  alterations  of  the  vagina  which  cause 
dystocia.     They  may  be  divided  into  (i)  congenital  and  (2)  acquired. 

(i)  Congenital  Affections  comprise  (a)  simple  narrowness  or  smallness  of 
the  passage,  (b)  atresia,  (c)  septa,  and  (d)  abnormal  terminations.  (a)  Small 
vagina:  This  is  not  described  by  most  authors.  In  Tamier  and  Budin  's  great  work* 
considerable  space  is  given  to  it.  Every  gynecologist  and  obstetrician  knows  that 
some  vaginas  are  unnaturally  small,  and  while  the  pregnant  state  softens  the 
tissue  and  makes  it  more  distensible,  such  vaginae  have  a  special  tendency  to 
laceration  during  labor,  (b)  Atresia  (Fig.  805);  This  term  should  be  used  to 
denote  congenital  imperforation  which  may  be  complete  or  partial.  It  is  of 
rare  occurrence  in  comparison  with  cicatricial  stricture — a  condition  which 
it  resembles.  It  exhibits  every  variation  in  regard  to  the  length  of  the 
constricted  portion  and  the  degree  of  imperforation.  From  the  standpoint 
of  dystocia,  atresia  and  cicatricial  stricture  may  be  considered  together  (see 
the  latter),  (c)  Septa:  The  vagina  may  be  divided  into  compartments  by 
septa,  longitudinal  and  transverse.  Longitudinal  septa  represent  the  abortive 
vagina  duplex.  They  form  large  "bridles"  between  the  anterior  and  posterior 
walls  and  almost  inevitably  obstruct  labor  and  bring  about  their  own  rupture. 
The  fetus  has  sometimes  been  strangled 
by  one  of  these  "bridles  "  getting  about 
its  neck.  Transverse  septa  may  be 
multiple.  They  should  not  be  con- 
founded with  atresia  in  which  the 
narrowed  area  has  length  as  well  as 
breadth,  for  the  transverse  septa  are 
mere  diaphragms  containing  openings 
of  various  sizes.  The  opening  in  one 
of  these  high  up  in  the  vagina  may  be 
taken  for  a  partially  open  os.  Such 
a  mistake  could  hardly  occur  if  the 
physician    always    feels    for  the   culs- 

de-sac.      Transverse  septa  offer  more  Fig.  805.— Atresia  of  the  Vagin.\. 

or  less  resistance  to  labor.  For  con- 
venience of  description  the  septa  will  be  considered  in  their  dystocic  aspects 
with  atresia  and  cicatricial  stenosis.  Abnormal  terminations:  In  the  absence 
of  external  genitals  the  vagina  has  been  known  to  empty  into  the  urethra 
or  rectum.  Impregnation  has  actually  occurred  in  both  abnormal  openings. 
Children  have  been  bom  through  the  anus,  and  have  even  been  delivered 
through  the  latter  with  forceps. f 

(2)  Acquired  Affections  maybe  grouped  under  the  title  cicatricial  stric- 
ture, a  term  which  fits  them  and  which  agrees  with  the  nomenclattire  of  other 
organs  of  tubular  structure  (rectum,  esophagus).  It  is  a  mistake  to  use  the 
word  atresia  in  this  connection.  Cicatricial  stricture  of  the  vagina:  This  is  due 
either  to  the  results  of  traumatism  or  to  local  infection.  In  either  case  loss  of  sub- 
stance occurs  by  sloughing,  ulceration,  or  healing  by  second  intention.  The  re- 
sulting scar  produces  a  constriction  in  some  portion  of  the  organ.  The  com- 
monest source  of  traumatic  stricture  is  child-birth,  which  may  operate  in  several 
ways;  thus,  impaction  of  the  fetal  head  in  the  vagina  may  end  in  sloughing,  so 
that  a  vesico-vaginal  or  recto-vaginal  fistula  may  develop  with  the  stricture. 
Again,  extensive  laceration  of  the  vagina,  such  as  results  from  improper  use 
of  the  forceps,  may  lead  to  similar  results.  Stricture  is  also  due  to  infective 
disease. 

*  Paris,  igoo.  t Tamier  and  Budin,  Edition  1900,  Paris. 


612  PATHOLOGICAL   LABOR. 

General  Consideration  of  Vaginal  Atresia,  Transverse  Septa,  and  Cicatricial 
Stricture. — These  three  conditions — the  two  former  congenital,  the  last  ac- 
quired— represent  collectively  the  atresia  of  text-books,  and  as  far  as  obstetrical 
practice  is  concerned  they  may  be  considered  together.  Such  a  study  has 
been  made  by  Maher,*  who  found  records  of  over  200  labors  with  such  com- 
plications. He  found  the  most  common  form  to  be  a  thin  transverse  septum 
situated  midway  in  the  vagina,  having  openings  of  varying  sizes.  In  one-half 
of  all  the  cases  the  obstruction  was  in  the  middle  of  the  vagina,  while  the 
remainder  were  divided  equally  between  the  upper  and  lower  thirds.  The  ob- 
structions may  exhibit  very  different  behavior  during  labor  according  to  their 
size  and  consistency.  They  may  stretch  and  allow  the  fetus  to  pass,  may 
lacerate,  or  oppose  such  resistance  to  the  passage  of  the  fetus  that  something 
above  the  obstruction  yields.  Thus,  ruptures  of  the  uterus  and  of  the  recto- 
vaginal walls  have  occurred  under  these  circumstances.  The  mortality  in  labor 
with  vaginal  obstruction  is  high  for  the  child  and  considerable  for  the  mother; 
Maher's  figures  are  41  and  13  per  cent,  respectively  (Fig.  805). 

Treatment. — In  the  majority  of  cases  spontaneous  delivery  is  possible. 
Each  case  must  be  managed  in  accordance  with  the  character  of  the  obstruction. 
Attempts  at  dilatation  will  probably  induce  labor,  hence  they  should  not  be 
employed  before  term  unless  premature  delivery  is  desired.  The  use  of  hydro- 
static bags,  digital  dilatation,  and  shallow  radiating  incisions  is  justifiable 
to  assist  nature.  Dilatation  must  be  complete  before  the  forceps  is  applied. 
After  delivery  the  constricted  point  should  not  be  allowed  to  close  again;  daily 
irrigation  and  dilatation  should  be  practised.  When  the  obstruction  is  un- 
yielding or  when  vesico-vaginal  fistula  coexists,  Cassarean  section  is  indicated ; 
but  if  the  obstruction  is  such  that  the  lochia  could  not  escape  by  the  vagina, 
the  Porro  operation  is  to  be  preferred. 

Rigidity  of  the  Vulva  ;  Persistent  Hymen. — The  vulva  may  exhibit  a  narrow- 
ness or  rigidity  as  a  whole  which  is  either  overcome  in  time  by  the  act  of  labor 
or  leads  to  multiple  lacerations.  Unnatural  rigidity  of  the  perineum  is  con- 
sidered under  the  head  of  the  management  of  this  structure  during  labor.  (Page 
480.)  Aside  from  the  vulva  proper,  resistance  may  be  encountered  from  the 
hymen,  naturally  in  primiparas  and  only  when  some  anomaly  of  formation 
is  present.  As  a  rule,  the  various  types  of  persistent  hymen  give  way  under 
the  pressure  of  the  child's  head,  but  exceptions  occur  in  which  labor  has  actually 
been  obstructed  by  this  structure,  such  a  state  of  affairs  having  been  confounded 
with  vaginismus.  Such  resistance  has  been  offered  in  these  cases  that  a  central 
laceration  of  the  perineum  has  occurred  through  which  the  child  was  born. 
The  treatment  of  resistant  hymen  is  simple,  consisting  in  gradual  digital  dilata- 
tion or  in  multiple  incisions. 

Obstructed  Labor  due  to  the  Levator  Ani. — (i)  Occasionally  instances  occur  in 
which  a  well-flexed  head  rotates  at  the  pelvic  floor,  bringing  the  sagittal  suture 
into  the  antero-posterior  diameter  of  the  outlet.  Then,  in  spite  of  strong 
uterine  contractions  and  an  elastic  pelvic  floor,  no  advance  occurs.  In  these 
cases  the  contraction  of  the  levator  ani  simultaneously  with  the  abdominal 
muscles  (voluntary  forces)  offers  just  enough  resistance  to  hold  back  the  head. 
Moderate  traction  of  a  few  pounds  with  the  forceps  will  be  sufficient  to 
exhaust  and  overdistend  the  fibers  of  the  muscle  and  overcome  the  obstruction. 
(2)  There  are  certain  cases  in  which  dangerous  obstruction  occurs  in  cases  of 
permanent  hypertrophy  and  shortening  of  the  levator  sufficient  to  necessitate 
craniotomy. 

*  "Virginia  Medical    Semi-monthly,"  1897,  11,  176. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


613 


XVII.  VAGINAL    AND    VULVAL   THROMBOSIS. 

OEDEMA. 


HEMATOMA    AND 


The  conditions  known  as  puerperal  hematoma  and  thrombosis  are  occa- 
sionally present  before  the  birth  of  the  child,  and  under  these  circumstances, 
if  sufficiently  large,  may  constitute  an  obstruction  to  the  presenting  part  (Fig. 
807).  This  accident  has  a  special  significance  in  twin  pregnancies,  for  while  it 
may  not  occur  sufficiently  early  to  obstruct  the  first  child,  it  may  interfere  with 
the  birth  of  the  second.    Treatment:  If  the  birth  of  the  child  is  actually  obstructed 

or  if  rupture  of  the  tumor  is  threat- 
ened, the  usual   practice   is  to   per- 
'^ '  ~'-  form   incision   and  extract  the  child 

/  )  as  soon  as  possible,  after  which  hemo- 

"     -    ■"  ~         .-'"  stasis   is  indicated.      (See   Puerperal 

Hemorrhages.)     CEdema  of  the  vulva 


Fio.  806. — Pedunculated  Superficial 
Thrombus  of  the  Vagina.  A, 
Tumor  drawn  to  left. 


Fig.  807. — Fibroid  Tumor  of  the  Right 
Labium  Majus  Resembling  a  Throm- 
bus. 


and  vagina  may  precede  labor,  in  which  case  it  is  due  to  renal  or  cardiac  disease; 
or  it  may  be  the  result  of  labor  itself  in  conditions  of  impaction  of  the  head  in  the 
vagina.  (Fig.  467.)  The  oedematous  tissues  are  very  vulnerable  and  prone  to 
gangrene.  The  indication  would  ordinarily  be  incision,  but  the  liability  to  septic 
accidents  is  a  contraindication  save  when  intervention  is  absolutely  necessary. 
When  a  rupture  at  the  vulval  outlet  is  threatened,  episiotomy  may  be  performed 
under  strict  asepsis. 


XVllI.  DISTENDED    BLADDER    AND    RECTUM.     CYSTOCELE,   RECTO- 
CELE,    VESICAL    CALCULUS. 

Distended  Bladder. — The  subject  of  retention  during  pregnancy  is  considered 
on  page  318.  The  condition  is  often  encountered  during  labor,  because  the 
presenting  part  may,  during  its  descent,  press  upon  the  neck  of  the  bladder. 
As  the  cervix  dilates,  the  summit  of  the  bladder  ascends  into  the  abdomen. 
Abdominal  palpation  will  therefore  readily  reveal  the  presence  of  the  fluctuating 
mass  in  front  of  the  uterus.     The  urine  collects  in  the  upper  part  of  the  bladder 


614 


PATHOLOGICAL   LABOR, 


and  impairs  the  efficacy  of  uterine  contractions.  An  elastic  male  catheter 
will  probably  be  required  to  reach  the  urine.  Owing  to  the  displacement  of 
the  meatus  and  urethra,  considerable  difficulty  may  be  encountered  in  entering 


Fig.   808. — Distended  Bladder  During 
Labor. 


Fig.   809. — Abdomen    Seen   in    Fig.    808, 
after  the  Use  of  the  Catheter. 


the  bladder.     It  may  even  be  necessary  to  push  back  the  advancing  head  in 
order  to  make  way  for  the  passage  of  the  instrument  (Figs.  808  and  809). 

Fecal  Accumulations. — The  extreme  type  of  retention  of  feces   known   as 
coprostasis,   in  which  ordinary  resources   are  insufficient  for  the   evacuation 

of  the  bowel,  constitutes  a  serious  mechanical  obstacle 
to  delivery  and  may  lead  to  grave  consequences  (Fig. 
810).  Such  a  condition  is  of  very  rare  occurrence,  for 
Tarnier*  saw  but  one  case.  One  would  expect  copro- 
stasis to  depend,  in  these  cases,  upon  some  malforma- 
tion of  the  rectum,  and  such  a  coincidence  is  known 
to  have  occurred.  These  fecal  accumulations  obstruct- 
ing a  portion  of  the  pelvic  cavity  must  have  the  same 
dystocic  effect  upon  labor  as  a  contracted  pelvis;  they 
prevent  engagement  of  the  head  and  lead  to  faulty 
positions.  Owing  to  the  degree  of  hardness  of  the 
feces,  removal  dan  hardly  be  effected  save  by  extract- 
ing them  piecemeal  with  the  finger  or  a  scoop. 

Cystocele. — A  large  cystocele  which  produces  in- 
version of  the  vagina  necessarily  causes  a  variety  of 
stenosis  of  that  portion  of  the  birth  tract.  Such  a 
condition  may  be  due  to  vesical  calculus  (page  615). 
An  ordinary  cystocele  may  be  remedied  for  the  time 
being  by  evacuating  the  bladder  with  a  catheter  so 
bent  as  to  reach  the  interior  of  the  pouch.  In  cases  of  obstructed  labor 
the  prolonged  compression  of  the  vagina  against  the  symphysis  may  result 
in  necrosis  and  fistula. 

Rectocele. — This   condition,   due  to  prolapse   of  the  vaginal  wall,  is   very 
rarely  encountered  during  labor.     When  present,  the  tumor  may  contain  either 
the  rectum  or  a  portion  of  the  intestines  (vaginal  enterocele).     The  diagnosis  is 
*  Tarnier  and  Budin,  vol.  iii,  p.  488 


Fig.  810. — Distended  Rec- 
tum Obstructing  Labor. 
—  {From  W.  C.  Lusk's 
frozen  section.) 


MATERNAL   DYSTOCIA    FROM   OBSTRUCTED   LABOR.  615 

made  by  digital  exploration  of  the  rectum.  Rectocele  is  not  a  formidable  com- 
plication of  labor  and  the  danger  of  impaction  and  pressure  accidents  is  not 
great.  An  enema  should  be  given,  after  which  the  prolapsed  vaginal  wall 
should  be  replaced  until  the  presenting  part  has  passed  the  obstruction.  (For 
consideration  of  enterocele,  see  page  614.) 

Vesical  Calculus. — Stone  in  the  bladder  very  rarely  complicates  pregnancy. 
Cases  have,  however,  been  recorded  in  which  calculi  have  obstructed  labor 
either  by  causing  vaginal  cystocele  or  through  impaction  at  the  pubis.  In  any 
case  of  obstruction  of  the  vagina  the  possibility  of  calculus  should  be  excluded 
by  passing  a  vesical  sound.  The  stone  must  be  removed  from  the  region  of 
the  birth  tract  by  placing  the  woman  in  the  modified  latero-prone  or  knee- 
elbow  position.  (See  Part  X.)  If  this  is  impossible,  vaginal  lithotomy  must  be 
performed;  the  wound  cannot  be  closed,  however,  until  after  delivery.  If 
a  small  calculus  could  become  impacted  in  such  a  way  as  to  impede  labor,  it 
should  be  possible  to  extract  it  through  the  urethra  after  previous  dilatation. 


XIX.    FRACTURES    OF   THE    PELVIS. 

In  a  pelvis  which  is  greatly  contracted  the  innominate  bones  may  sometimes 
be  fractured  by  instrumental  delivery.  This  is  inexcusable,  for  with  such  a 
pelvis  forcible  instrumental  delivery  is  contraindicated,  a  safer  treatment 
being  some  major  operative  procedure.  On  the  other  hand,  rachitis  or  some 
other  pathological  process  may  render  the  bone  so  fragile  that  it  will  break 
during  an  instrumental  delivery  through  no  fault  of  the  obstetrician.  In  certain 
cases,  especially  of  elderly  primipars,  the  coccyx  is  broken  by  the  passage 
of  the  fetal  head.  The  condition  of  coccygodynia  follows.  This  is  most  painful, 
and  often  demands  subsequent  removal  of  the  broken  piece  (Figs.  852,  853, 
854). 

XX.    DIASTASIS    OF   THE    PELVIC    JOINTS. 

Etiology:  This  condition  is  the  result  of  the  natural  traumatism  of  labor 
and  may  affect  the  symphysis  or  one  of  the  sacro-iliac  joints.  All  three  of 
the  interpelvic  articulations  may  be  involved  at  the  same  time.  A  general 
predisposition  to  this  is  furnished  by  the  relaxation  which  the  pelvic  joints 
undergo  during  pregnancy.  Multiparae  are  predisposed  by  reason  of  relaxation 
from  repeated  pregnancies.  Pelvic  deformity  constitutes  a  strong  predis- 
position; so  do  unusual  size  of  the  fetus,  disease  of  the  joints,  etc.  A  special 
class  of  cases  is  due  to  the  use  of  the  forceps.  In  some  cases  the  mechanism 
of  the  injury  is  obscure,  none  of  the  preceding  factors  having  aided  in  its  pro- 
duction. This  accident  occurs  with  considerable  frequency,  especially  in 
osteomalacic,  generally  contracted,  and  funnel-shaped  pelves.  The  joint  most 
frequently  ruptured  is  the  symphysis.  Symptoms  :  Unless  the  patient  happens 
to  be  under  the  influence  of  an  anesthetic,  she  usually  feels  "  something  give 
way  "  at  the  time  of  the  accident.  The  limbs  are  seen  to  be  rotated  outward 
and  are  immovable.  Pain,  both  spontaneous  and  induced,  is  usually  present 
over  the  affected  joint.  When  the  symphysis  ruptures,  the  vagina  is  usually 
lacerated,  and  the  finger  can  recognize  the  injury  by  palpation.  The  prognosis 
is  good  as  a  rule.  The  treatment  of  ruptured  symphysis  corresponds  to  the 
after-treatment  of  symphyseotomy.  The  pelvis  should  be  immobilized  by 
strips  of  adhesive  plaster  or  plaster-of-Paris  and  the  patient  should  remain 
in  bed  four  or  five  weeks  before  attempting  to  walk. 


616  PATHOLOGICAL   LABOR. 


XXI.   PELVIC    DEFORMITY. 

Definition, — A  deviation  in  size,  shape,  or  mobility  from  the  normal  type, 
sufficient  to  cause  unfavorable  symptoms  during  pregnancy  and  labor.  The 
larger  part  of  these  abnormal  forms  are  contractions  full  of  danger  for  both 
mother  and  child,  and  often  demand  instrumental  delivery.  The  deformity 
may  exist  in  any  one  or  all  of  the  diameters,  the  most  frequent  and  most  serious 
being  those  which  affect  the  pelvic  inlet.  Besides  mechanical  obstruction  in 
pelvic  deformity,  the  physician  often  has  to  deal  with  unfavorable  mechanisms 
of  labor  caused  by  abnormal  posture,  position,  or  presentation. 

Frequency. — The  frequency  of  pelvic  contraction  in  native-born  American 
women  has  been  estimated  at  2  per  cent.,  and  among  foreign-born  women 
at  6  per  cent.*  It  is,  however,  probable  that  its  frequency  in  American 
women,  especially  among  the  poorer  classes  and  in  the  large  cities,  has 
been  underestimated.  According  to  Winckel,  pelvic  contraction  occurs  in  from  10 
to  15  percent,  of  women,  but  it  is  sufficiently  marked  to  cause  symptoms  in  only 
5  per  cent.  Contracted  pelves  are  believed  to  be  rarer  in  America  than  abroad. 
However,  Williams  states  that  they  are  nearly  as  common  in  Baltimore  as  on 
the  continent  of  Europe.  He  found  that  from  12  to  15  per  cent,  of  women  show 
them,  but  most  of  these  were  not  marked  enough  to  impede  labor.  Reliable 
statistics,  however,  are  generally  wanting;  and  it  must  happen  that  the 
lesser  degrees  of  pelvic  deformity  pass  unnoticed,  particularly  when  no  syste- 
matic measurements  are  made,  and  when  the  attention  of  the  accoucheur  is 
directed  to  the  measurements  of  the  various  pelvic  deformities  only  by  some 
actual  obstruction  to  the  passage  of  the  child.  It  has  been  only  in  recent  years 
that  the  subject  of  pelvimetry  has  been  given  the  place  it  deserves  in  conserva- 
tive obstetrics.  The  regular  and  routine  adoption  of  the  examination  of  preg- 
nancy (seepage  148),  including  pelvimetry,  will  prove  to  any  one  the  frequency 
of  contracted  pelves.  Then,  and  only  then,  will  the  real  cause  of  many  anomalies 
in  labor  be  apparent,  such  as  malpresentations  and  malpositions,  prolonged 
labor  and  uterine  inertia;  and  the  prematiure  induction  of  labor,  the  use  of  the 
forceps,  of  version,  symphyseotomy,  and  cranioclast  will  not  be  empirical,  but 
will  be  employed  for  a  rational  and  sufficient  cause.  In  the  last  ten  years  the 
statement  has  frequently  been  made  to  the  author  by  graduates  attending  his 
lectures  and  clinics,  that  in  several  years'  practice  they  have  never  observed  a 
single  case  of  deformed  pelvis,  but  their  ratio  of  difficult  forceps,  versions, 
perforations,  and  even  vesico-vaginal  fistulas  was  ftdly  up  to  the  average. 

My  conclusions  from  a  critical  study  of  1200  consecutive  hospital  cases  are 
as  follows  f:  (i)  Of  1200  consecutive  cases  measured,  499,  or  41.58  per  cent., 
were  American-born  women;  215,  or  17.91  per  cent.,  Irish;  130,  or  10.83  per 
cent.,  Russian;  105,  or  8.75  per  cent.,  German;  30,  or  2.50  per  cent.,  black, 
etc.  (2)  Contracted  pelves  occurred  in  44  cases,  once  in  27.27  cases,  or  in 
3.66  per  cent.  Generally  contracted  pelves  occurred  in  30  cases,  once  in  40 
cases,  or  2.50  per  cent.  Flattened  pelves  occirrred  in  14  cases,  once  in  85.71 
cases,  or  1.16  per  cent.  No  irregiilar  forms  of  contraction  were  observed.  (3) 
Twenty,  or  45.45  per  cent.,  of  my  cases  of  pelvic  contraction  were  among  Amer- 
ican-born women,  and  deformity  occurred  once  in  24.95  of  these  cases,  or  in  4 
per  cent.  (4)  Three,  or  6.81  per  cent.,  of  the  contracted  pelves  were  among 
black  women,  and  deformit}'-  occurred  once  in  10  of  these  cases,  or  in  10  per  cent. 
(5)  My  material  gives  a  frequency  of  contracted  pelves  (1200  cases,  3.66  per 

*  "Trans.  Amer.  Gyn.  Soc  ,"   1890. 

t  "Pelvic  Deformity  in  New  York  City,"  "Trans.  Amer.  Gyn.  Soc,"  1Q02. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR.  617 

cent.)  midway  between  the  conclusions  of  Williams  (Baltimore,  looo  cases, 
13. 1  per  cent.);  Crossen  (St.  Louis,  800  cases,  7  per  cent.);  Reynolds  (Boston, 
2127  cases,  1. 13  per  cent.);  and  Flint  (New  York,  10,223  cases,  1.42  per  cent.). 
(6)  My  statistics — 3.66  per  cent,  of  contractions  in  1200  cases — differ  from  those 
of  England  (F.  Barnes,*  of  London,  38,065  cases,  0.5  per  cent.);  of  France,  5  to 
2 1. 1 1  per  cent.t;  Germany,  {  9  to  9  per  cent.;  Switzerland,  8  to  16  per  cent.; 
Austria-Hungary,^  2.44  to  7.8  per  cent.;  Russia, ||  1.2  to  5.1  per  cent.;  Italy,** 
18.13  psJ^  cent.;  Holland, ft  3.51  per  cent.  (7)  Special  or  irregular  forms  of  pel- 
vic contraction,  such  as  osteomalacia,  obliquely  contracted,  coxalgic,  double  cox- 
algic,  spondylolisthetic  and  kyphotic,  or  fractured  pelvis,  are  uncommon  in  this 
country.  (8)  The  generally  contracted  pelvis  is  the  deformity  most  frequently 
met  with  in  New  York.  I  found  twice  as  many  generally  contracted  as  flat- 
tened pelves  in  my  material  (30.14).  Williams  found  practically  the  same 
condition  in  Baltimore  (79.45).  (9)  Records  kept  of  private  and  consultation 
cases  in  New  York  over  a  period  of  ten  years  show  a  somewhat  higher  percentage 
than  the  results  obtained  from  the  1200  hospital  cases — namely,  about  5  per 
cent,  for  all  deformities,  the  generally  contracted  pelvis  being  twice  as  frequent 
as  the  flattened.  The  frequency  seems  to  vary  in  different  countries.  The 
Saxon  pelves  are  most  often  contracted,  which  explains  why  Zweifel  has  per- 
formed ninety  Caesarean  sections.  They  are  common  enough  to  explain  why 
the  second  stage  often  lasts  four  or  five  hours,  why  face  presentations  and  other 
anomalies  are  numerous.  Deformed  pelves  are  frequent  enough  anywhere 
to  demand  that  the  physician  be  familiar  with  the  different  varieties,  and  also 
that  he  be  versed  in  the  art  of  pelvimetry.  Schauta's  estimate  is  twenty  per 
cent,  in  Austria.  There  are  numerous  geographical  variations  which  do  not 
yet  admit  of  a  definite  explanation.  Among  the  native  American  women  to- 
day the  rachitic  pelvis  is  very  infrequent,  the  most  common  types  being  the 
generally  contracted  and  those  following  spinal  deformity. 

General  Etiology  and  Development. — The  etiological  factors  which  may  be 
considered  as  producing  deformed  pelves  are:  (i)  Defective  development;  (2) 
disease  of  the  pelvic  bones;  (3)  irregularities  in  the  junction  of  the  pelvic  bones; 
(4)  disease  of  those  parts  of  the  skeleton  which  are  carried  by  the  pelvis;  (5) 
disease  of  those  parts  of  the  skeleton  which  carry  the  body-weight.  (See  Classi- 
fication, page  617.)  The  normal  adult  pelvis  is  the  complicated  outcome  of  a 
combination  of  various  factors.     (See  The  Passages,  page  391,  Part  IV.) 

Classification  and  Description  of  Different  Varieties. — Classification  has  been 
many  times  attempted,  but  with  most  unsatisfactory  results.  Different  bases 
of  classification  have  been  taken, — e.  g.,  the  causes  or  effects, — but  the  variations 
are  so  numerous  that  the  simplest  and  most  scientific  arrangement  is  based 
on  the  location  and  character  of  the  deformity.  The  classification  I  adopt 
is  practically  Schauta's. 

{A)  Anomalies  of  the  Pelvis  as  a  Result  of  Defective  Development. — I.  Generally 
symmetrically  contracted,  non-rachitic  pelvis,  justo-minor  or  small  round 
pelvis:  (i)  The  infantile  type;  (2)  the  masculine  or  strong  type;  (3)  the  dwarf 
type.  II.  Simple  flat,  non-rachitic  pelvis.  III.  Generally  contracted  flat, 
non-rachitic  pelvis.  IV.  Narrow,  funnel-shaped  pelvis.  Fetal  or  "lying- 
down"  pelvis.     V.   Imperfect  development  of  one  sacral  ala  (Naegele  pelvis). 

*  International  Gynecological  Congress  at  Geneva,  1S96    (reported  in   "Centralbl.  f. 
Gynak."). 

t  Fochier,  Pinard:  Loc.  cit.  J  Loc.  cit.  §  Pawlik:  Loc.  cit. 

I|  Hugenberger:  "Petersburg,  med.  Wochen.,"  1872,  in. 
**  Pestalozza :  Geneva  Congress.  1896.  tt  Treub:   Geneva  Congress,  1896. 


618 


PATHOLOGICAL   LABOR. 


VI.  Imperfect   development  of  both  sacral  alae  (Robert  pelvis).     VII.  Gener- 
ally equally  enlarged  pelvis,  justo-major  pelvis.     VIII.  Split  pelvis. 

{B)  Anomalies  of  the  Pelvis  as  a  Result  of  Disease  of  the  Pelvic  Bones. — I. 
Rachitis.  II.  Osteomalacia.  III.  New  growths.  IV.  Fracture.  V.  Atrophy, 
caries,  necrosis. 

(C)  Anomalies  in  the  Junction  of  the  Pelvic  Bones. — I.  Synostosis  at  the 
symphysis.  II.  Synostosis  at  one  or  both  sacro-iliac  joints.  III.  Synostosis 
at  the  sacro-coccygeal  joint.  IV.  Exaggerated  motion  or  separation  of  the 
pelvic  joints. 

{D)  Anomalies  of  the  Pelvis  due  to  Disease  of  those  Parts  of  the  Skeleton  which 

are  Carried  by  the  Pelvis. — I.  Spondylolis- 
thesis. II.  Kyphosis.  III.  Skoliosis.  IV. 
Kypho-skoliosis.  V.  Assimilation.  VI.  Lor- 
dosis. 

(E)  Anom.alies  of  the  Pelvis  due  to  Disease 
of  the  W eight-hearing  Parts  of  the  Skeleton. — 
I.  Coxitis.  II.  Luxation  of  the  head  of  one 
femur.  III.  Luxation  of  the  heads  of  both 
femora.  IV.  Unilateral  or  bilateral  club-foot. 
V.  The  absence  or  deformity  of  one  or  both 
lower  extremities. 


A.  ANOMALIES  OF  THE  PELVIS  THE  RESULT 
OF  FAULTY  DEVELOPMENT. 

I.  Generally  Symmetrically  Contracted, 
Non-rachitic  Pelvis.  Pelvis  .^quabiliter  Justo- 
minor,  or  Small  Round  Pelvis  (Figs.  8ii ,  814). 
— In  _the  generally  contracted  pelvis  the  fe- 
male shape  is  preserved  but  the  size  is  dimin- 
ished. Under  this  heading  are  grouped  three 
sub- varieties,  (i)  The  infantile  or  juvenile 
type,  the  bones  of  which  are  delicate  and  small ; 
(2)  the  masculine  type,  strong  pelvis,  the 
bones  of  which  are  strong  and  large;  (3) 
the  dwarf  type,  which  is  extremely  small, 
and  whose  bones,  like  those  of  the  infant 
pelvis,  are  connected  by  cartilaginous  instead 
of  bony  union  (Fig.  813). 

The    divisions    between    the    innominate 

bones  are  distinct,  as  well  as  those  between 

the  vertebras  of  the  sacrum.     In  this  form  of 

pelvis  all  of  the  diameters  have  their  normal 

relations,  but  the  measurements  of  the  entire 

pelvis  are  less  than  normal.     This  pelvis  merges  very  gradually  into  other  forms, 

as  the  generally  contracted  flat,  the  simple  flat,  and  the  transversely  contracted 

pelvis. 

Frequency  and  Etiology. — This  type  of  deformity  is  often  found,  particularly 
in  the  class  frequenting  the  free  hospitals  and  dispensaries.  It  is  the  most 
frequent  type  in  America.  I  found  it  in  2.50  per  cent,  of  my  cases.  These 
women  have  been  born  to  hard  work  and  unhealthful  environment.  However, 
this  malformation  is  sometimes  met  with  in  those  who  are  otherwise  well  formed. 


Pig.  811.— Generally  Symmetri- 
cally, Non-rachitic,  Contrac- 
ted Pelvis.  Justo-minor  or 
Small  Round  Pelvis. 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED   LABOR.  619 


Clinical  Characteristics. — The  transverse  concavity  of  the  sacrum  is  increased; 
the  sacral  promontory  is  pushed  upward,  but  is  not  prominent.  While  the 
posterior  superior  iliac  spines  are  further  apart  than  normal,  the  iliac  crests 
and  spines  are  closer  together.  The  transverse  diameters  are  decreased;  the 
conjugate  of  the  superior  strait  is  shorter  than  normal;  the  side  walls  of  the 
pelvis  can  be  so  easily  felt  that  it  is  not  uncommon  for  the  finger  to  be  able  to 
follow  the  iliopectineal  line.  This  form  of  pelvis  is  not,  strictly  speaking,  a 
copy  of  the  normal  adult  pelvis  in  small  dimensions,  for  it  has  some  of  the 
characteristics  of  the  infantile  pelvis.  As  a  rule,  women  with  the  generally 
contracted   pelvis  are   short  in  stature  and  slender,  but  there  are  exceptions. 

In  the  forms  of  the  generally  contracted  pelvis 
most  commonly  seen  the  contraction  is  usually 
slight.  In  certain  instances  the  pelvic  outlet 
is  contracted  transversely.  The  dwarf  variety 
is  most  unusual,  and  is  found  only  in  dwarfs. 
Diagnosis. — The  generally  contracted  pel- 
vis can  be  easily  differentiated  from  any  other 
deformed  type — the  rachitic,  for  example — 
when  it  is  remembered  that  the  measure- 
ments, although  less  than  normal,  are  sym- 
//       ■-' "•  -^i^  metrically  so.     There  is  one  possible  exception 

only — the  external  conjugate  diameter;  this, 


Fig.  8i2. — Achondroplasic  Dwarf. 
—  (Depaul.) 


Fig.  S13. — Dwarf  Pelvis. 


on  account  of  the  peculiarities  of  the  sacrum,  which  is  not  situated  so  anteriorly 
as  the  normal,  may  be  longer  than  usual.  Another  important  measurement 
is  that  of  the  pelvic  circumference,  which  is  always  much  less  than  normal. 
The  internal  examination  should  be  carefully  made,  especially  the  estimation 
of  the  transverse  diameters. 

Prognosis. — Difficulty  begins  with  the  onset  of  labor  and  increases  with 
its  progress.  The  head  is  overflexed  with  a  consequent  prominence  of 
the  posterior  fontanelle,  while  the  sagittal  suture  lies  commonly  in  an  oblique 
diameter  (Fig.  639).  Descent  is  slow,  but  there  is  rarely  the  lateral  obliquity 
which  is  seen  in  flat  pelves.     Breech  presentations  are  especially  to  be  dreaded 


620 


PATHOLOGICAL  LABOR. 


in  this  form  of  pelvis,  for  it  is  very  difficult  to  free  the  legs  and  arms,  and  to 
bring  the  head  down  through  the  contracted  canal.  Although  the  mother 
does  not  suffer  from  injuries  to  the  soft  parts  which  are  incident  to  labor  in 
some  forms  of  contracted  pelvis,  still  the  pelvic  joints  are  liable  to  be  ruptured 
and  eclampsia  is  very  common.  As  for  the  child,  the  caput  succedaneum  is  of 
unusual  size  and  is  just  over  the  smaller  fontanelle.  The  cranial  bones  greatly 
overlap  (Fig.   582). 

II.  Simple  Flat,  Non-rachitic  Pelvis  (Fig.  894). — A  frequent  form  of  de- 
formed pelvis  consists  in  the  shortening  of  the  antero-posterior  diameter.     This 

variety  is  common  and  was  the  first 
contracted  pelvis  to  be  recognized. 
It  was  not  till  later  that  the  distinc- 
tion between  it  and  the  rachitic  fiat 
pelvis  was  made  clear. 

Frequency  and  Etiology. — The  etiol- 
ogy is  obscure,  although,  as  a  rule,  this 
type  of  pelvis  is  probably  congenital. 
It  is  a  very  common  type  and  is  found 
as  often  among  the  upper  classes  as 
among  the  lower;  and  it  is  also  as 
common  in  the  otherwise  well-formed 
woman  as  in  the  stunted.  Various 
predisposing  causes  of  this  deformity 
have  been  suggested,  such  as  over- 
exertion in  youth;  excessive  burden- 
bearing;  the  combination  of  weak 
pelvic  ligaments  and  a  heavy  trunk; 
arrested  rachitis.  It  is  probable  that 
heredity  is  an  important  factor,  for 
it  has  been  noted  frequently  in  newly 
born  children  and  fetuses. 

Clinical  Characteristics. — It  is  only 
the  antero-posterior  diameter  in  this 
pelvis  which  departs  from  the  normal, 
the  other  pelvic  diameters  being  as 
a  rule  undisturbed.  The  degree  of 
distortion  is  never  great.  The  sacrum 
is  displaced  forward  to  a  slight  degree 
and  the  cartilage  between  the  second 
and  third  sacral  vertebrse  is  unusually 
prominent,  often  making  a  double 
promontory.  The  mutual  relations 
between  the  iliac  crests  and  spines  are  almost  nil.  Contrary  to  the  condition 
in  the  generally  contracted  pelvis,  vaginal  palpation  will  reveal  the  lateral 
pelvic  walls  only  with  difficulty.     The  pelvis  is  perfectly  symmetrical. 

Diagnosis. — Unless  there  has  been  difficulty  in  previous  labors  there  will  be 
nothing  but  the  measurements  to  call  attention  to  the  condition,  which  is  easily 
overlooked.  In  the  presence  of  a  double  promontory  the  one  nearest  the 
symphysis  must  be  used  in  measuring  the  conjugate. 

Prognosis. — Pendulous  abdomen  is  often  present  in  this  form  of  pelvis. 
Labor  need  not  be  seriously  interfered  with,  although  instrumental  delivery 
maybe  necessary  under  certain  conditions,  such  as  feebleness  of  the  uterine  con- 


FiG.  814. — Symmetrically  Contracted  Pel- 
vis FROM  Complete  Assimilation  of  the 
Fifth  Lumbar  Vertebra  with  the  Sa- 
crum. 


Fig.   815. — Diagram    of    Pelvic    Inlet    of 
Fig.   814. 


MATERNAL   DYSTOCIA   FROM  OBSTRUCTED   LABOR.  621 

tractions  or  oversize  of  the  fetal  head.  The  first  stage  is  generally  protracted, 
for  the  head  is  longer  than  usual  in  engaging.  After  engagement  has  taken 
place,  the  course  of  labor  runs  smoothly,  although  the  maternal  strength  may  have 
been  much  exhausted  by  the  demands  made  upon  it  before  engagement  took 
place.  This  condition  of  affairs  will,  of  course,  naturally  protract  the  course  of 
labor.  The  head  accommodates  itself  to  the  shape  of  the  pelvis;  this  accounts 
for  its  transverse  position  and  slight  extension  as  it  enters  the  pelvis;  which 
allows  the  palpation  of  the  bregma  (Fig.  645).  The  anterior  parietal  position 
is  assumed,  since  the  sagittal  suture  is  brought  near  the  sacral  promontory 
(Figs.  685  and  686).  Very  infrequently  the  head  assumes  the  posterior  parietal 
position,  so  that  the  sagittal  suture  approaches  the  symphysis  (Figs.  688  and 
689).  This  is  generally  confined  to  primiparas.  Early  rupture  of  the  mem- 
branes is  frequent.  It  is  probable  that  in  the  majority  of  cases  labor  termin- 
ates spontaneously.  Faulty  presentations  and  prolapse  of  the  cord  or  extremities 
frequently  occur.  Necrosis  of  the  maternal  soft  parts  may  be  expected  from  the 
long  pressure  to  which  they  are  subjected.  As  to  the  child,  although  the  caput 
succedaneum  is  not  extreme,  there  are  often  depressions  or  grooves  on  the  head 
varying  with  the  position  of  the  pressure  to  which  it  has  been  subjected. 

III.  Generally  Contracted  Flat,  Non-rachitic  Pelvis  (Fig.  895). — As  the  name 
indicates,  this  pelvis  is  characterized  by  the  peculiarities  of  both  the  generally 
contracted  and  the  flat  pelvis. 

Frequency  and  Etiology. — This  pelvis  results  from  congenital  defect  but  not 
from  rachitis,  and  is  rather  common.  Some  authorities  believe  that  it  can  be 
caused  by  too  early  walking  or  long  standing  on  the  feet  in  the  first  years  of  life. 

Clinical  Characteristics. — With  the  exception  of  the  diagonal  conjugate, 
which  may  be  increased  on  account  of  the  elevation  of  the  sacrum,  all  of  the 
diameters  are  decreased,  particularly  the  conjugate  of  the  inlet.  The  sacrum 
is  small,  its  promontory  is  much  elevated  but  not  prominent,  while  its  position 
is  considerably  posterior  in  comparison  with  the  normal.  The  alee  as  well  as 
the  innominate  bones  are  not  fully  developed.  Two  points  should  serve  to 
differentiate  this  type  from  the  rachitic  pelvis — the  abnormally  posterior  posi- 
tion of  the  sacrum  and  the  fact  that  the  anterior  half  of  the  pelvic  circumference 
is  only  slightly  broadened.  Otherwise  there  are  various  points  of  resemblance 
between  this  and  the  rachitic  pelvis.  The  entire  pelvis  is  smaller  than  normal. 
The  mechanism  of  labor  is  similar  to  that  in  flat  pelves. 

Diagnosis. — An  absolute  diagnosis  can  be  made  only  by  the  direct  measure- 
ment of  the  various  diameters,  and  is  even  then  difficult.  Although  these 
diameters  throughout  bear  a  resemblance  to  those  of  the  generally  equally  con- 
tracted pelvis,  the  diagonal  diameter  is  an  exception,  being  longer  in  the  last- 
named.  This  factor,  together  with  the  ease  with  which  the  side  walls  of  the 
pelvis  can  be  reached  by  the  internal  finger,  will  help  in  the  diagnosis. 

Prognosis. — More  difficulty  in  labor  is  experienced  in  this  pelvis  than  in  the 
simple  flat  variety,  for  the  oblique  diameters  do  not  afford  extra  room  for  the 
head  of  the  fetus,  the  whole  pelvis  being  undersized. 

IV.  The  Narrow,  Male,  Funnel-shaped  Pelvis  ;  Fetal  or  Lying-down  or  Un- 
developed Pelvis  (Fig.  816). — The  name  suggests  both  the  shape  and  the  etiology 
of  this  type  of  pelvis.  The  subject  of  funnel-shaped  pelvis  has  been  much 
neglected. 

Frequency. — This  has  been  considered  an  exceedingly  rare  variety,  but  is 
often  found  when  the  pelvis  is  systematically  measured.  Schauta  estimated 
5.90  per  cent,  of  funnel  pelves  in  5000  cases. 

Etiology. — It  is  due  to  the  absence  of  the  forces  upon  which  the  evolution  of 


622 


PATHOLOGICAL  LABOR. 


the  normal  pelvis  depends.  (Page  391.)  Those  unfortunates  who,  owing  to 
infantile  paralysis  or  for  other  reasons,  have  never  walked  are  the  ones  in 
whom  it  is  most  markedly  found.  A  suggestion  of  this  type  is  also  sometimes 
found  in  ver;^'-  young  girls.  Schauta  pointed  out  the  fact  that  this  pelvis  is 
generally  due  to  maldevelopment  by  which  the  walls  of  the  pelvis  are  lengthened 
and  the  body-weight  is  thrown  backward  on  the  sacrum. 

Clinical  Characteristics. — The  characteristics  of  the  fetal  pelvis  persist — 
usually  length  and  narrowness  of  the  sacrum  and  elevation  of  the  promontory 
which  gives  a  longer  diagonal  conjugate  than  usual.  The  whole  pelvis  is  very 
narrow  and  deep  and  there  is  not  the  normal  width  at  the  hips.  The  sacrum  is 
unusually  straight.  The  transverse  diameter  of  the  outlet  is  contracted,  and 
Schauta  showed  that  contraction  in  the  pelvic  outlet  may  be  in  any  diameter. 
The  sacrum  is  far  back  between  the  iliac  bones.     The  spinal  column  is  normal. 

Another  Form  of  Funnel  Pelvis. — 
A  kyphosis  in  the  upper  vertebras 
gives  a  lordosis  in  the  lower  part. 
If  the  kyphosis  is  lower,  the  influ- 
ence on  the  pelvis  is  marked.  Sup- 
pose the  kyphosis  is  in  the  lumbar 
region,  there  is  no  compensatory 
lordosis,  but  in  order  to  enable  the 
patient  to  stand  upright  there  are 
changes  in  the  pelvis  causing  an 
enlargement  at  the  superior  strait. 
Rotation  of  the  sacrum  backward 
causes  an  increase  in  the  superior 
and  a  decrease  in  the  inferior  strait. 
The  pelvis  assumes  more  or  less  the 
horizontal  position.  The  iliac  bones 
are  spread  apart  by  the  sacrum, 
causing  the  distance  between  the 
spines  and  crests  to  be  increased. 
Great  tension  is  put  on  the  ilio- 
sacral  ligaments,  causing  a  drag  on 
the  ischia,  tending  to  spread  the 
bones  above  -and  causing  a  con- 
traction below  from  side  to  side. 
Hence  the  pelvic  outlet  is  dimin- 
ished both  transversely  and  antero-posteriorly.  The  tension  is  on  the  ilio- 
femoral ligaments,  and  this  throws  the  ilia  outward  and  the  ischia  inward.  A 
kyphosis,  in  order  to  produce  this,  must  take  place  in  early  life.  Later,  the 
pelvis  is  tilted  but  no  such  change  takes  place. 

Diagnosis. — The  diagnosis  may  be  easy  if  measurements  are  taken.  Usually 
the  deformity  is  overlooked.  The  kyphosis  itself  should  give  the  clue.  The 
measurements  of  the  inlet  and  outlet  must  be  compared.  (See  Pelvimetry.) 
The  diameters  of  the  outlet  are  less  than  normal,  while  those  of  the  inlet  are 
normal  or  even  greater.  When  this  deformity  exists  in  an  extreme  degree,  so 
that  the  inlet  and  the  pelvic  cavity  are  contracted,  there  is  a  still  greater  degree 
of  contraction,  comparatively  speaking,  in  the  outlet.  The  internal  examination 
of  the  pelvic  canal  is  of  great  service  in  making  the  diagnosis,  for  it  will  clearly 
reveal  the  shelving  walls  converging  toward  the  outlet,  the  contraction  of  the 
pelvic  arch,  and  the  close  relation  of  the  ischiac  tuberosities  and  spines. 


Fig.  816. — Narrow,    Male,    Funnel-shaped 
Fetal  or  Lying-down  Pelvis. — (Ahlfeld.) 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR.  623 

Prognosis. — In  more  than  one-half  of  the  cases  labor  has  terminated 
fatally.  It  may  be  possible  to  deliver  with  forceps,  since  spontaneous 
delivery  takes  place  only  in  the  slightest  degree  of  this  deformity.  If  the 
transverse  diameter  is  less  than  three  inches  (7.62  cm.)  and  the  antero-pos- 
terior  diameter  is  also  contracted,  symphyseotomy  is  indicated,  while  still 
greater  contraction  will  demand  Caesarean  section.  Hence  in  these  forms  the 
ordinary  means  of  pelvimetry  are  not  sufficient  for  making  the  diagnosis.  If 
the  diagnosis  is  not  made,  the  child  will  be  dragged  out  through  the  contracted 
outlet.  Faulty  positions  of  the  head  at  the  outlet  are  common.  The  power 
of  expulsion  is  generally  weak.  Lacerations  and  necrosis  of  the  soft  parts  are 
most  frequent,  and  on  account  of  the  convergence  of  the  pubic  rami  there  is 
great  danger  of  perineal  laceration. 

V.  Imperfect  Development  of  One  Lateral  Mass  of  Sacrum.  Naegele's  Pelvis. 
Obliquely  Deformed  or  Contracted  Pelvis.  Obliquely  Ovate  Pelvis.  Single 
Oblique  Pelvis  (Figs.  817,  818,  819,  820). — Naegele  first  described  this  in  1806, 
and  published  a  work  in  1839  in  which  he  had  collected  some  thirty  cases. 

Frequency  and  Etiology. — By  many  obstetricians  this  pelvis  is  considered 
extremely  rare,  but  careful  observation  will  result  in  the  discovery  of  one  or 
two  in  the  course  of  the  average  practice  in  obstetrics.  There  are  two  theories 
as  to  etiology:  (i)  Failure  of  development  of  the  alas  of  the  sacrum  on  one 
side  from  absence  of  bony  nuclei;  (2)  inflammatory  changes  in  the  same  place 
causing  synostosis.  Reasons  for  the  congenital  view  are:  (i)  Such  deformities 
have  been  observed  in  intrauterine  life;  (2.)  if  it  were  due  to  inflammation, 
traces  of  this  trouble  would  be  left  behind — but  these  are  not  found.  The 
direction  of  distortion  of  the  innominate  bones  is  upward  and  backward  on 
the  sacrum.  This  condition  would  not  be  possible  in  the  presence  of  primary 
ankylosis.  The  atrophy  of  the  part  embraces  the  whole  length  of  the  sacrum. 
It  is  to-day  accepted  that  the  first  theory  is  the  correct  one.  The  ossification 
of  the  bones  is  secondary.  Even  children  having  this  deformity  before  ankylosis 
takes  place  have  the  oval  pelvis,  because  the  well  side  in  developing  draws 
over  the  affected  side.  As  soon  as  the  patient  begins  to  walk,  the  body-weight 
is  applied  more  to  the  leg  of  the  diseased  side,  causing  an  adhesive  inflammation 
leading  to  synostosis.  Sometimes  this  union  does  not  take  place,  but  the 
pelvis  is  deformed  notwithstanding. 

Clinical  Characteristics. — The  sacral  ala  on  the  deformed  side  is  atrophied 
or  entirely  wanting,  -while  there  exists  a  synostosis  between  the  sacrum  and 
the  iliac  bone.  The  asymmetrical  narrow  sacrum  faces  the  deformed  side, 
the  promontory  being  actually  twisted  over  toward  the  contracted  side.  The 
pelvic  inlet  is  oval  in  shape,  with  the  tapering  end  on  the  deformed  side  (Fig. 
819).  The  crests  of  the  pelvis  are  markedly  asymmetrical.  The  symphysis 
is  deflected  from  the  middle  line  to  the  unaffected  side,  while  the  pubic  arch  is 
contracted  and  deflected  (Figs.  819  and  902).  The  external  surface  of  the  sym- 
physis faces  toward  the  diseased  side  instead  of  directly  forward.  The  ilio- 
pectineal  line  of  the  affected  side  is  almost  a  straight  line,  while  the  ilium  on 
the  sound  side  has  a  greater  curve  in  its  anterior  part  than  normal,  but  in 
every  other  particular  is  practically  unchanged.  The  posterior  superior  spine 
of  the  ilium  approaches  the  sacral  spines.  The  oblique  diameter  drawn  from 
the  superior  posterior  spine  of  the  ilium  of  the  deformed  side  to  the  anterior 
superior  spine  of  the  normal  side  is  increased  (Fig.  820).  Careful  internal 
pelvimetry  will  detect  considerable  decrease  in  the  oblique  diameter  drawn 
from  the  point  just  above  the  center  of  the  obturator  foramen  on  the  con- 
tracted side  to  the  opposite  sacro-iliac  synchondrosis.     Pressure  of  the  femur 


624 


PATHOLOGICAL   LABOR. 


on  the  diseased  side  is  exerted  in  an  upward  direction,  so  that  the  innominate 

bone  is  pressed  upward  and 
inward,  while  on  the  sound 
side  femoral  pressure  is  di- 
rected upward  and  outward. 
Thus  the  sound  side  is  en- 
larged. This  fact  is  of  im- 
portance because  in  the 
mechanism  of  labor  there  is 
only  one  side  of  the  pelvis 
for  the  fetus.  The  normal 
true  conjugate  plays  no 
part.  The  diameter  to  be 
considered  skirts  the  poste- 
rior wall  at  the  sacro-iliac 
synchondrosis.  There  is  no 
shortening  of  the  true  con- 
jugate, and  therefore  these 
pelves  are  often  unrecog- 
nized. 

Diagnosis. — This  is  read- 
ily made  in  routine  pelvic 
examinations,  although 
without  careful  measure- 
ments the  deformity  may 
be  easily  overlooked.  In  the 
'  internal     examination     the 

asymmetry  ought  to  be  rec- 
ognized by  the  ischial  spines. 
The  contracted  pubic  arch 
and  distorted  promontor}' 
would  also  be  noticed. 


Fig.    817. — Oval     Oblique     Pelvis 

{Budin.) 


u 


Fig.  818. — Oval  Oblique  Pelvis  of   Naegele. 
VIC  Inlet. —  {Author's  collection.) 


The    distance   is    measured 
from  the  spine  of  the  last  lum- 
OF     Naegele.  bar    vertebra    to    the     anterior 

superior  spines  of  the  iha,  and 
from  the  last  lumbar  spine  to 
the  posterior  superior  spine. 
Then  the  measure  is  taken  from 
the  anterior  superior  spine  of 
one  side  to  the  posterior  supe- 
rior spine  of  the  opposite  side; 
from  the  posterior  superior  spine 
of  the  ilium  on  one  side  to  the 
tuber  ischii  on  the  other;  from 
the  posterior  superior  spines  of 
the  ilia  to  the  inferior  edge  of 
the  symphysis  pubis;  from  the 
inferior  edge  of  the  pubis  to  the 
spines  of  the  ischium,  and  again 
from  the  spines  to  the  nearest 
sacral  borders.  The  longest 
measurement  between  the  ischial 
spines  and  the  inferior  border  of 
the  pubis  is  on  the  decreased 
side,  while  the  reverse  is  true 
Pel-  of  the  distance  between  these 
spines  and  the  sacrum.  . 


MATERNAL   DYSTOCIA    FROM   OBSTRUCTED   LABOR. 


{J2t 


The  majority  of  these  cases  have  been  diagnosed  after  death. 
Ueves  the  diagnosis  to  be 
free  from  difficulty  when 
there  is  a  great  difference 
between  the  sides.  The 
patient  may  exhibit  no  limp 
in  her  gait,  but  a  careful 
history  of  her  early  life 
should  be  obtained.  Phy- 
sical examination  may  also 
reveal  healed  sinuses.  A 
rectal  examination  is  valu- 
able for  detecting  an  anky- 
losed  joint.  Externally  the 
most  valuable  measurement 
is  that  from  the  trochanter 
major  of  one  side  to  the  iliac 
crest  of  the  other,  and  vice 
versa. 

Prognosis.  —  The  results 
are  usually  fatal.  Probably 
two-thirds  of  the  cases  pass- 
ing into  labor  have  ended 
in  death.  If  the  deformity 
is  great,  the  child  must 
pass  through  the  healthy 
side  of  the  pelvis,  as  the 
contracted  side  is  not  large 
enough  to  admit  any  part 
of  the  fetus.  The  mechan- 
ism is  similar  to  that  of  the 
generally  contracted  pelvis. 
The  occiput  descends  first, 
as  the  head  is  extremely 
flexed.  If  the  breech  pre- 
sents, the  prognosis  is  more 
unfavorable,  for  it  may  be 
impossible  for  the  head  to 
pass.  The  mortality  of  the 
mothers  is  80  per  cent.,  ac- 
cording to  Litzmann.  The 
prognosis  in  respect  to  the 
mother  will  necessarily  de- 
pend upon  several  factors. 
Eighty  per  cent,  as  quoted 
is  thought  to  be  too  high 
for  maternal  mortalit}',  and 
it  is  to  be  accounted  for 
by  the  use  of  inappropriate 
treatment,  and  also  by  the 
fact  that  often  the  condi- 
tion was  not  recognized 
40 


Zweifel  be- 


FiG.     819. — Oval 


Oblique     Pelvis 
0udin.) 


OF     Naegele. 


Fig.  S20. 


—Oval  Oblique  Pelvis  of  Naegele. 
VIC  Outlet. — (Aiiihor's  collection.) 


Pel- 


626 


PATHOLOGICAL   LABOR. 


early  enough  for  the  use  of  suitable  therapeutic  measures.     Various  accidents 
are  apt  to  take  place  during  labor,  such  as  ruptures,  fistulas,  fractures,  etc. 

Treatment. — This  differs  according  to  the  extent  of  the  deformity.  If  the 
inferior  strait  is  contracted,  Caesarean  section  should  be  performed.  Farabeuf 
recommends  ischio-pubotomy.  (See  Operations,  Part  X.)  If  the  attendant  is  in 
doubt,  Caesarean  section  should  be  performed,  since  unless  the  degree  of  deformity 
is  slight,  forceps  and  version  are  not  generally  attended  by  good  results. 

VI.  Imperfect  Development  of  both  Lateral  Masses  of  the  Sacrum,  Robert's 

Pelvis.  The  Ankylotic  Pelvis. 
Transversely  Contracted  Pel- 
vis (Figs.  821,  822). — Robert 
was  the  first  to  describe  this 
pelvis  in  1842.  It  is  closely 
related  to  the  Naegele  pelvis. 
Frequency  and  etiology:  This 
is  the  rarest  of  contracted 
pelves,  only  eight  cases  hav- 
ing been  reported.  It  is 
due  to  failure  of  develop- 
ment of  the  sacral  alae  on 
both  sides.  There  is  gener- 
ally synostosis  on  both  sides, 
and  the  sacro-iliac  synchon- 
drosis is  absent.  Clinical 
characteristics:  The  sacral 
alas  are  either  absent  or 
poorly  developed.  The  nar- 
row sacrum  has  an  extremely 
elevated  promontory,  felt  on 
internal  examination.  The 
spines  and  tuberosities  of 
the  ischium  are  more  closely 
approximated  than  norm-  • 
ally.  The  transverse  pelvic 
diameters  are  much  de- 
creased, while  on  account  of 
the  slight  anterior  displace- 
ment of  the  sacrum  the 
conjugate  of  the  superior 
strait  is  diminished.  The 
transverse  diameter  of  the 
inlet  is  particularly  short- 
ened, varying,  according  to 
Kleinwachter,  from  2.76  to  3.94  inches  (7  to  10  cm.),  while  that  of  the  out- 
let is  from  0.88  to  2.76  inches  (2.25  to  6  cm.).  The  pubic  angle  is  diminished. 
Asymmetry  of  the  Robert  pelvis  sometimes  exists.  Diagnosis  is  based  upon 
the  above  condition.  Prognosis:  Caesarean  section  with  its  attendant  dangers 
is  nearly  always  indicated.  Treatment:  Perforation  and  extraction  may  be 
performed  within  certain  limits,  a  case  in  which  the  transverse  diameter  of  the 
pelvic  inlet  measures  3.1  inches  (7.8  cm.)  and  that  of  the  outlet  2  inches  (5 
cm.)  is  supposed  to  represent  the  extreme  limit  of  its  applicability.  Caesarean 
section  has  been  performed  in  the  majority  of  the  cases. 


Fig.  821. — Double  Oblique  Pelvis  of  Robert. 


Fig.  822. 


-Double  Oblique  Pelvis  of  Robert. 
gram  of  pelvic  inlet  of  Fig.  821. 


Dia- 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


627 


Fig.  823. — Generally  Equally  Enlarged  Pelvis. 
JusTO-MAjOR  Pelvis.  Pelvic  Inlet. — {Author's 
collection.) 


VII.  Generally  Equally  Enlarged  Pelvis.  Pelvis  ^quabiliter  Justo-major. 
Giant  Pelvis.  Justo-major  Pelvis  (Figs.  823  and  824). — This  pelvis  is  occa- 
sionally observed  in  women  of  medium  height,  although  it  also  sometimes 
accompanies  a  gigantic  stature.  Frequency  and  etiology:  This  condition  is  often 
merely  congenital,  with  no  other  particular  explanation.  Clinical  characteristics : 
In  this  pelvis  all  the  diameters, 

although  preserving  normal 
proportions,  are  increased. 
The  condition  is  seldom  no- 
ticed, especially  if  not  present 
in  an  extreme  degree.  During 
pregnancy  the  woman  is  liable 
to  have  increased  pressure 
symptoms.  This  is  due  to 
the  low  position  of  the  uterus 
in  the  roomy  pelvis.  Consti- 
pation, urinary  symptoms, 
oedema  of  the  vulva,  varicose 
veins,  and  difficult  locomotion 
are  common  in  pregnancy. 
Diagnosis:  This  is  rarely  made, 
but  if  measurements  show  a 
general  and  symmetrical  in- 
crease, diagnosis  of  a  justomajor  pelvis  is  justifiable.  The  promontory  cannot 
be  reached  by  internal  examination,  nor  are  the  side  walls  of  the  pelvis 
easily  accessible.  Prognosis:  Labor  is  usually  not  disturbed  by  this  anomaly, 
although  the  majority  of  obstetricians  consider  that  delivery  is  apt  to  be 
precipitate  on  account  of  the  large  size  of  the  birth  canal. 

VIII.  Split  Pelvis.     Inverted  Pelvis  (Fig.  825). — The  name  and  illustration 

indicate  the  deformity.  Frequency 
and  etiology:  This  condition  repre- 
sents an  anomaly  of  non-union, 
comparable  and  usually  associated 
with  such  malformations  as  ex- 
strophy of  the  bladder,  myelomen- 
ingocele, etc.  As  a  complication  of 
labor  it  is  one  of  the  rarest  of  pelvic 
anomalies.  Clinical  characteristics: 
Although  the  deformity  of  this  t3'-pe 
most  frequently  concerns  the  sym- 
physis pubis,  still  in  some  cases  the 
sacrum  as  well  as  the  lower  part  of  the 
vertebral  column  is  fissured  at  birth. 
In  the  separation  of  the  pubic  bones 
the  heads  of  the  femora,  pressing 
upward,  force  the  innominate  bones 
outward  and  backward,  resulting  in 
the  approach  of  the  posterior  superior  spines  of  the  ilium  behind  the  sacrum, 
which  is  pushed  inward.  Thus  there  is  created  a  groove  posterior  to  the 
sacrum,  from  which  circumstance  this  variety  of  pelvis  receives  the  name- 
of  "inverted"  pelvis.  The  space  where  the  bones  fail  to  meet  is  usually 
filled  with"  fibrous  tissue.     Exstrophy  of  the  bladder  usually  accompanies  this 


Fig.  S24. — Generally  Equally  Enlarged 
Pelvis.  Justo-major  Pelvis.  Pelvic 
Outlet. — {Author's  collection.) 


628 


PATHOLOGICAL   LABOR. 


Fig.   S25. — Split  or  Inverted  Pelvis. 


Fig.   827.— Pelvic    Inlet   of   Fig.   826. 


Fig.  826. — Pelvis  Deformed  from  In- 
fantile Paralysis  of  the  Right  Side 
WITH  Atrophy  of  the  Corresponding 
Femur.  , 


Fig.  828. — Pelvis  Deformed  from 
Faulty  Development  of  the  Sa- 
cral Vertebra. 


/^ 


Fig.  829. — Deformed  Pelvis  from  Faulty 
Development  of  the  Sacrum. 


Fig.  830. — Pelvis  Deformed  from  Faulty 
Development  of  the  Sacral  Vertebra. 


MATERNAL  DYSTOCIA  FROM  OBSTRUCTED  LABOR. 


629 


deformity.  Not  infrequently  there  are  other  congenital  defects.  It  is  not 
often  that  this  pelvis  is  observed  in  a  woman  who  bears  children,  though  there 
are  several  recorded  cases.  The  diagnosis  is  perfectly  clear.  Prognosis:  No 
obstacle  to  labor  is  presented  by  the  deformity,  and  it  may  be  compared 
with  the  justo-major  pelvis.  There  is  no  indication  for  obstetric  treatment 
during  labor.  There  is  almost  invariably  prolapsus  uteri  after  labor.  In  the 
case  of  cleavage  of  the  sacrum  there  is  often  present  a  meningocele  projecting 
into  the  pelvis  which  may  offer  a  serious  obstruction  to  the  passage  of  the  child . 


B.    ANOMALIES   DUE   TO   DISEASE   OF   THE   PELVIC   BONES. 

I.  Rachitis    or    Rickets.     Rachitic    Pelvis. — This    deformity    has    doubtless 
always  existed.     Hippocrates  and  Galen  knew  of  it,  but  Glisson  (1650)   first 


"■nffMSimmM 


Fig.  S3 1. — Zone  of  Ossification  in  a 
Normal  Epiphysis  (Microscopic):  i, 
Hyaline  cartilage;  2,  zone  of  beginning 
proliferation  of  the  cartilage;  3,  columns 
of  cartilage-cells  arranged  in  rows;  4, 
columns  of  enlarged  cartilage-cells;  5, 
first  zone  of  calcification;  6,  layer  of 
osteoblasts  in  first  zone  of  ossification; 
7,  fully  developed  cancellous  tissue 
(spongiosa) ;  8  and  9,  blood-vessels  in 
transverse  and  longitudinal  section. 


"B^is 


Fig.  832. — Zone  of  Ossification  in  a 
Rachitic  Epiphysis  (Microscopic):  i, 
Transition  of  normal  hyaline  cartilage 
to  proliferating  cells;  2,  zone  of  carti- 
lage-cells arranged  in  rows;  3,  cellule- 
fibrous  medullary  spaces  containing 
blood-vessels  in  the  region  of  the  pro- 
liferated and  enlarged  cartilage-cells;  4, 
island  of  calcified  cartilaginous  tissue; 
5,  columns  of  osteoid  and  fully  devel- 
oped calcified  bone-tissue;  6,  columns  of 
osteoid  tissue  not  containing  lime-salts; 
7,  like  3,  with  the  blood-vessel  in  trans- 
verse section. 


described  the  disease.  Rickets  of  the  newly  born  child  may  be  one  of  two 
varieties — fetal  or  congenital.  It  was  the  former  that  was  familiar  to  the 
ancients,  as  the  latter  has  been  recognized  only  of  late  years.     Both  types  of 


630 


PATHOLOGICAL  LABOR. 


this  disease  begin  in  intrauterine  life,  but  while  in  the  fetal  form  the  stigmata 
of  the  disease  are  fully  developed  at  birth,  in  the  congenital  form  the  evidences 
of  the  disease  continue  their  development  after  birth.  Fetal  rachitis  has  been 
called  a  disease  of  the  periosteal  cartilage.  There  is  an  exuberance  of  growth 
of  this  part  while  the  process  of  calcification  is  faulty.  In  rachitis  the  growth 
of  the  cartilage  and  subperiosteal  tissue  is  defective  as  well  as  the  process  of 
ca,lcification. 

Frequency  and  Etiology  of  Rachitis. — From  fifty  to  seventy  per  cent,  of 
dispensary  patients  in  Glasgow  and  Vienna  exhibit  traces  of  this  affection.  -In 
America  it  is  especially  seen  in  the  colored  race.  In  the  lower  animals  there 
occurs  a  disease  similar  to  rickets.  Malnutrition  of  the  mother  and  deficiency 
in  lime  salts  seem  to  be  the  most  important  etiological  factors. 

Pathology  of  Rachitis. — Bone  is  normally  formed  (i)  under  the  periosteum, 

(2)  from  cartilage,  (3)  from  the  med- 
ullary canal.  All  of  these  may  be 
affected  by  the  disease.     The  essen- 


FiG.  833. — Sagittal  Section  of  a  Rachi- 
tic Pelvis.  Note  the  false  sacral  pro- 
montories and  the  disappearance  of  the 
vertical  concavity  of  sacrum. 


Fig.  834. — Sagittal  Section  of  a  Rachi- 
tic Pelvis.  Contraction  at  the  pelvic 
inlet  with  exaggeration  of  the  vertical 
concavity  of  the  sacrum. 


tial  fact  is  that  there  is  excessive  bone-formation  while  calcification  is  limited. 
Hence  it  is  a  primary  disease — never  caused  by  solution  of  pre-formed  calcified 
bone.  Roloff  noted  that  in  zoological  gardens  lions  fed  on  meat  without  bones 
develop  a  similar  condition  (lahme)  on  account  of  the  lack  of  calcium  (Figs.  831, 
832).      _ 

Clinical  Characteristics  of  Rachitis. — Rachitis  is  a  disease  of  children  occurring 
during  the  first  three  years  of  life.  If  the  child  has  already  learned  to  walk,  it 
ceases  to  do  so.  Hence,  one  should  always  ask  "When  did  the  patient  learn  to 
walk?"  The  disease  gives  rise  to  soft  bones,  with  their  resulting  deformities. 
The  epiphyses  of  the  long  bones  are  enlarged  ("knock-knee,  rachitic  rosary"). 
This  is  more  marked  on  the  pleural  than  on  the  pectoral  side  of  the  ribs.  Pigeon - 
breast  often  results,  especially  if  adenoids  are  associated.  The  head  is  more  or  less 
square  or  blunt.  The  bones  of  the  skull  have  flat  areas,  which  are  thinned,  and 
spoken  of  as  craniotabes.    Gastro-intestinal  symptoms  are  marked  and  marasmus 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


631 


may  result.  The  various  parts  of  the  body  are  disproportionate,  the  abdomen  being 
very  large.  Hydrocephalus  and  enlarged  thyroid  are  often  present.  The  pelvis 
and  spinal  column  are  subject  to  deformities.  In  certain  cases  the  head  is 
inclined  laterally  upon  the  axis  of  the  spine.  The  long  bones  are  often  curved, 
while  their  spontaneous  fracture  is  not  uncommon.  Diagnosis  from  recog- 
nition of  the  clinical  characteristics  as  given  above  should  be  simple  (Figs.  833, 
834,835). 

Varieties  of  Rachitic  Pelves. — There  are  several  varieties  of  deformed  pelvis 
resulting  from  the  inroads  of  this  disease.  The  most  frequent  is  (i)  flat  rachitic 
pelvis,  in  which,  although  all  of  the  diameters  are  shortened,  the  antero-posterior 
is  most  affected.  (2)  The  simple  fiat,  rachitic  pelvis,  in  which  the  transverse 
diameters  suffer  no  change.  (3)  The  gener- 
ally equally  contracted'  rachitic  pelvis.  (4) 
The  pseudo-osteomalacic  pelvis,  which  comes 
to  resemble  the  pelvis  of  osteomalacia  from 
the  effect  of  pressure  on  the  soft  rachitic 
bones.  (5)  Very  rare  forms  of  distorted  pelves, 
in  addition  to  the  foregoing,  result  from 
rachitic  affections  of  the  spinal  column. 

Clinical  Characteristics  of  Rachitic  Pelves. — 
Three  influences  serve  to  modify  the  pelvis 
in  rachitis:  (i)  Arrest  of  development  occa- 
sioned by  the  progress  of  the  disease;  (2) 
the  pressure  exerted  both  by  the  superim- 
posed and  the  subjacent  skeleton;  and  lastly 
(3)  the  "pull"  of  the  ligaments  and  muscles 
attached  to  the  pelvic  bones.  The  pelvis 
as  a  whole  is  undersized,  having  a  dis- 
torted inlet  which  is  often  kidney-shaped 
or  rarely  like  the  figure  8.  The  pelvic  cavity 
is  very  shallow.  The  pull  of  the  obturator 
muscles  upon  the  soft  bones  widens  the 
pubic  arch,  and  if  great  flattening  is  pres- 
ent, there  will  result  the  figure  8  pelvis. 
The  promontory  of  the  sacrum  is  abnormally 
prominent.  The  obliquity  of  the  pelvis  is 
greatly  increased.  The  epiphyses  are  pecu- 
liarly altered,  while  the  presence  of  other 
characteristics  of  rachitis  adds  to  the  cer- 
tainty of  the  diagnosis.  As  a  rule,  the  bones 
of   a   rachitic  pelvis    are    abnormally  fragile 

and  small;  rarely  they  are  coarser  and  heavier  than  normal,  (i)  and  (2)  Rachitic 
flat  pelvis:  As  a  result  of  softening  of  the  bones  the  child  learns  to  walk  late, 
or  if  it  has  walked  ceases  to  do  so  for  a  time  (Figs.  836,  837,  838,  839).  The 
bones  are  soft  and  the  child  does  not  walk,  but  sits  up;  hence  the  pressure  of 
the  body-weight  is  not  counteracted  by  the  upward  pressure  of  the  femora. 
The  broadening  becomes  marked  and  the  transverse  diameter  is  shorter  than 
normal.  The  iliac  bones  are  flared  out  so  that  the  iliac  spines  are  farther 
apart  than  the  crests.  The  sacrum  tends  to  rotate,  imparting  a  backward 
impulse  to  the  lower  part,  but  this  is  offset  by  the  firm  grasp  of  the  ligaments, 
and  a  curve  is  the  result.  Hence  the  antero-posterior  diameter  of  the  inferior 
strait  is  shortened.     The  bodies  of  the  sacral  vertebrae  are  pushed  forward  at 


Fig.  835. — Rachitic  Dwarf.  De- 
livered by  C.-ESAREAN  Section. — 
(Author's  case.) 


632 


PATHOLOGICAL   LABOR. 


r^^: 


Fig.  836. — Rachitic  Pelvis.  Diminution  of 
all  diameters,  especially  of  the  antero-pos- 
terior. 


Fig.  837. — Pelvic   Inlet  of  Fig.   836. 


Fig.  838. — Simple  Flat  Rachitic  Pelvis.   Note  the       Fig.  83Q. — Pelvic  Inlet  of  Fig.  83$ 
false  sacral  promontories. 


Fig.  840.— Generally  Equally  Contracted        Fig.  841.— Pelvic  Inlet  of  Fig.  840. 
Rachitic  Pelvis. 


MATERNAL   DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


633 


the  expense  of  the  alae,  making  the  anterior  surface  of  the  sacrum  straight  or 
convex.  The  child  sits  on  the  tubera  ischii  without  the  upward  pressure  of 
the  femora  to  counteract,  and  the  transverse  diameter  of  the  inferior  strait 
becomes  broadened,  and  there  is  also  a  flaring  outward  of  the  ischiac  bones. 
The  area  of  the  superior  strait  remains  about  the  same,  but  the  relations  are 
distorted.  Owing  to  the  backward  movement  of  the  sacrum,  there  is  more 
room  in  the  pelvis,  although  the  ex- 
ternal antero-posterior  diameter  of 
Baudelocque  is  less  than  normal. 
The  interference  with  labor  ends 
when  the  head  has  passed  the  supe- 
rior strait.  The  effect  of  the  deform- 
ity varies  according  to  the  extent. 
As  to  the  measurements  of  the  pelvis, 
a  true  conjugate,  one  less  than  2}. 
inches  (5.5  cm.),  is  absolutely  con- 
tracted; 2^  inches  (6.35  cm.)  to  3 
inches  (7.62  cm.)  is  a  deformity  of 
the  third  degree;  3  inches  (7.62  cm.) 
to  3^  inches  (8.89  cm.)  is  a  deformity 
of  the  second  degree,  and  the  child 
may  be  born  spontaneously  or  with  the 
aid  of  the  forceps;  3Hnches  (8.89  cm.) 
t0  4i  inches  (10.795  cm.)  is  a  deformity 
of  the  first  degree,  and  the  first  child 
is  usually  born  spontaneously.  Con- 
tractions of  the  first  degree  are  of 
little  importance.  The  child's  head 
is  3 1  inches  (9.5  cm.)  for  the  biparie- 
tal  diameter,  but  this  is  capable  of 
considerable  shortening.  In  a  flat 
rachitic  pelvis  the  head  is  less  flexed, 
being  semi-extended.  The  two  fon- 
tanelles  are  on  the  same  level.  The 
head  becomes  tilted  in  normal  cases 
so  that  the  sagittal  suture  lies  nearer 
the  promontory  of  the  sacrum.  This 
is  called  Naegele's  obliquity.  (Pages 
518.)  In  flat  rachitic  pelves  this  is 
accentuated  and  the  sagittal  suture 
lies  in  front  of  the  sacrum  and  the 
parietal  bone  presents — anterior  par- 
ietal presentation.  This  increases  till 
finally  the  ear  is  left  behind  the  sym- 
physis  pubis.     Then    rotation    takes 

place,  causing  the  sagittal  suture  to  leave  the  sacrum.  In  a  few  cases 
the  sagittal  suture  is  anterior.  The  complication  is  then  more  serious,  as 
the  head  becomes  wedged  above  the  symphysis  pubis.  Whenever  the  two 
fontanelles  are  felt  equally,  a  flat  rachitic  pelvis  may  be  suspected.  After 
the  head  has  passed  the  superior  strait  the  mechanism  of  labor  is  normal. 
Presentation  by  the  posterior  parietal  bone  is  serious  because  the  head  is 
wedged  on  the  symphysis  pubis.      The   child  cannot   be   bom   spontaneously. 


Fig.    842.^Pseudo-osteomal.a.cic    Rachitic 
Pelvis. — (.4 ntlior's  collection.) 


634 


PATHOLOGICAL   LABOR. 


Great  pressure  is  exerted  on  the  posterior  parietal  bone  by  the  sacrum,  causing  a 
depression  in  the  bone.  Sometimes  this  depression  is  spoon-shaped.  It  is  quite 
likely  that  the  brain  has  been  injured.  By  palpation  only  a  vague  idea  of  the 
size  of  the  head  can  be  obtained.  (3)  The  generally  equally  contracted  rachitic 
pelvis:  It  is  chiefly  characterized  by  arrested  development  (Figs.  840, 
841).  It  entails  contraction  of  the  transverse  diameter  such  as  is  seen  in 
the  fetal  pelvis.  This  form  is  very  rare  and  it  leaves  the  shape  of  the 
pelvic  brim  little  changed  from  normal,  since  the  ravages  of  the  disease 
have  done  their  work  at  such  an  early  age  that  the  child  did  not  sit  up 
or  walk  till  recovery  had  taken  place.  Consequently  the  processes  which 
serve  to  change  the  shape  of  the  pelvis  when  disease  offers  them  in  a  favorable 
condition,  have  not  had  a  chance  to  exert  their  influences.  (4)  The  pseudo-osteo- 
malacic  pelvis:  This  is  the  result  of  several  conditions  the  opposite  of  those 
considered  in  the  last  section  (Fig.  842).  The  deformity  of  this  type  is 
striking,  for  the  disease  progresses  while  the  child  is  walking  and  perchance 
carrying  heavy  weights  (Fig.  842).  From  the  action  of  the  two  forces, 
superimposed  and  subjacent,  the  pelvis  is  distorted  to  an  extreme  degree. 
The  acetabula  are  pushed  inward  so  that  they  encroach  on  the  pelvic  space. 

The  innominate  bones  yield 
to  the  pressure  exerted  upon 
them  and  are  bent  laterally, 
while  the  sacrum  is  pressed 
downward  and  bent  also  in 
the  same  direction.  The  de- 
formities are  far  advanced  be- 
fore the  disease  has  exhausted 
itself,  and  the  pelvis  is  fixed  in 
its  distorted  form. 

Diagnosis  of  Rachitic  Pel- 
ves.— Signs  of  rachitis  in  other 
parts  of  the  body  will  make 
the  diagnosis  more  clear.  The 
history  of  infantile  rachitis 
can  also  generally  be  elicited. 
The  relative  position  of  the  crests  and  spines  of  the  ilia  is  of  important  diagnostic 
significance  (Fig.  843).  The  history  and  personal  appearance  must  also  be  taken 
into  consideration.  After  rachitis  in  childhood  the  woman  is  generally  observed 
to  be  short  with  thick,  curved  limbs,  enlarged  joints,  square  head,  and  chicken- 
breast.  The  abdomen  is  short,  and  on  this  account,  and  because  of  the  failure 
of  engagement  of  the  presenting  part,  when  pregnancy  occurs  it  hangs  far  for- 
ward and  downward  in  a  characteristic  manner.  Besides  walking  late,  the  ra- 
chitic child  is  late  in  teething.  Not  infrequently  a  double  sacral  promontory  is 
observed  in  these  patients.  In  some  cases  the  lumbar  vertebras  are  curved  inward 
so  far  that  they  offer  an  obstruction  above  the  brim.  This  results  from  rachitis 
of  the  spine.  In  measuring  the  effective  conjugate  from  the  symph^^sis  the  outer 
point  must  be  taken  above  the  sacrum.  To  differentiate  this  pelvis  from  that  of 
osteomalacia  is  not  difficult,  for  there  are  characteristics  belonging  to  the  latter 
which  clearly  distinguish  it,  and,  besides,  the  other  rachitic  signs  come  into  play — 
those  found  elsewhere  in  the  body  and  the  direction  of  the  crests  of  the  ilia. 
After  the  disease  has  run  its  course  the  consistency  of  the  bones  is  farm  and  hard. 
II.  Osteomalacia.  Osteomalacic  Pelvis  (Figs.  844  to  848). — In  English  works 
the  disease  is  called   "  malacosteon."     The  pelvis  in  a  patient  suffering  from 


Fig.  843. — -Diameters  of  the  Iliac  Spines  and 
Crests  in  a  Rachitic  Pelvis  Compared.  D.M., 
Intercristal  diameter;  D.A.,  interspinal  diameter. 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED  LABOR. 


635 


this  disease  is  called  the  "osteomalacic,"  "malacosteon,"  or  "  Y-shaped  pelvis." 
It  is  also  known  as  the  "beak-shaped  "  or  "rostrate  pelvis."  Frequency  and 
etiology:  It  is  rare  in  America  but  very  common  around  the  head-waters  of 
the  Rhine.  Litzmann's  statistics  (1892)  show  that  of  131  cases  11  were  in 
males,  85  in  pregnant  or  puerperal  women,  and  35  in  non-pregnant  women.  It 
is  essentially  a  disease  of  women,  being  in  them  about  five  times  more  fre- 
quent than  in  men.  It  occurs  during  pregnancy  or  during  the  puerperium. 
This  disease  is  caused  by  the  production  of  soft  bone  in  the  adult  through  the 
absorption  of  lime  salts  (Fig.  844).  This  bone  is  unable  to  resist  pressure 
without  being  distorted  into  bizarre  forms.  It  usually  occurs  between  thirty 
and  fifty  years  of  age,  in  pregnant  women  or  in  those  who  have  had  children, 

and  especially  in  those  who  have  had  many 
children.  It  is  observed  in  animals  kept  in 
zoological  gardens,  where  it  is  usually 
thought  to  differ  from  the  similar  condi- 
tion in  human  beings.  Varieties  of  osteo- 
malacic pelves:  The  relative  deformity  from 
malacosteon  may  be  expressed  by  several 
forms  of  pelves:  (i)  Oblong,  in  which  the 
antero-posterior  diameter  is  increased  (Fig. 
845);  (2)   oblong  rostrated,  dhlong  m  shsL-pe 


Fig.  844. — Microscopic  Section 
through  an  osteomalacic  bone. 
I ,  Remains  of  calcified  bone-sub- 
stance; 2,  decalcified  bone-substance; 
3,  large  medullary  spaces  due  to  the 
disappearance  of  bone-substance;  4, 
Haversian  canals. 


Fig.  845. — Osteomalacic  Pelvis.  Oblong  In- 
let BEFORE  Much  Deformity  Has  Occurred. 
Weight  of  this  pelvis  fifteen  ounces.  Weight 
of  healthy  bony  pelvis  about  thirty  ounces. — 
{Author's  collection.) 


with  anterior  beak  (Figs.  846,  847,  848);  (3)  rostrated,  with  beak  in  front;  (4) 
cordiform,  heart-shaped.  This  last  form  is  very  rare.  Pathology:  The  old  idea 
was  that  bones  affected  with  this  disease  contain  far  less  calcium  than  the  normal 
bone.  In  1895  Curatulo  and  Turelli  made  animal  experiments.  They  estimated 
the  total  excretion  of  carbonic  acid,  lime,  and  phosphoric  acid.  Then  they  cut 
out  the  ovaries  and  found  certain  changes.  The  animals  did  not  breathe  so 
rapidly  and  excreted  less  lime  and  phosphoric  acid.  Hence  it  was  shown  the 
ovaries  increase  the  excretion  of  these  products.  In  1896  Denecke  estimated 
the  amount  of  lime  and  phosphorus  excreted  by  osteomalacic  women ;  the  ovaries 
were  then  removed.     In  a  few  weeks  there  was  a  marked  decrease  in  the  excre- 


636 


PATHOLOGICAL   LABOR. 


Fig.    846. — Osteomalacic    Pelvis.      Oblong     Ros 
TRATED.     Pelvic   Inlet. 


tion  of  these  substances.     In   1897   Senator  recorded   a  case   of  osteomalacia. 

Excretion  estimates  were  made  and  the  diet  carefully  regulated,  while  thyroid 

extract  was  administered.  It 
was  found  that  the  excretion 
of  lime  and  phosphorus  was 
increased.  Ovarian  extract 
caused  an  increase  of  nearly 
double  that  noted  under  the 
thyroid  treatment.  Clinical 
characteristics:  The  patient 
suffers  from  rheumatoid 
pains,  inability  to  walk,  and 
difficult  labors.  The  pelvic 
bones  become  very  soft  so 
that  in  extreme  cases  they  can 
actually  be  bent  by  the  hand ; 
they  are  also  very  painful. 
The  pelvis  naturally  becomes 
much  distorted  and  the  sym- 
physis pubis  comes  to  resem- 
ble a  beak,  because  the  heads 
of  the  femora  drive  the  in- 
nominate bones  inward,  while 
the  symphysis  is  held  in  place 
by  its  muscular  attachments. 
On  internal  examination  the 
finger  may  be  laid  in  the  hol- 
low of  this  deformity  (Fig. 
848) .  The  pubic  arch  is  much 
narrowed  and  the  true  con- 
jugate is  very  short.  The 
promontory  of  the  sacrum  is 
very  prominent,  being  forced 
downward  and  forward,  while 
the  tip  of  this  bone  and  the 
coccyx  bend  so  sharply  for- 
ward that  the  outlet  of  the 
pelvis  is  almost  completely 
obstructed.  The  tubera  ischii 
are  displaced  outward  so  that 
the  transverse  diameter  of  the 
outlet  is  increased.  The  pa- 
tient suffers  from  dyspnea 
and  cough.  The  bones  be- 
come very  porous  and  light, 
containing  much  cancellous 
tissue.  This  tissue  contains 
large  cavities,  which  may  be 
froin  two  to  four  millimeters 
in  length.    The  pelvis  actually 

collapses  and  the  sufferer  always  loses  markedly  in  height, — even  as  much  as  a 

foot  in  some  cases, — while,  unable  even  to  stand,  she  is  confined  to  her  bed.     It 


Fig.  847. — Diagram  of   Pelvic    Ixlet   of   Fig. 


Fig.    848. — Osteomalacic    Pelvis.       Oblong    Ros- 
trated.    Pelvic  Outlet. 


MATERNAL  DYSTOCIA    FROM   OBSTRUCTED   LABOR. 


637 


occurs  during  pregnancy, 
diagnosed  as  rheumatism, 
woman  is  somewhat  lame 
difficult  labor  follows. 
The  second  child  will 
probably  be  born  dead 
while  the  following  will  be 
delivered  by  craniotomy 
or  abdominal  section. 
(See  Osteomalacia  in 
Diseases  of  Pregnancy.) 
Diagnosis:  The  length  of 
the  true  conjugate  is  not 
a  criterion  of  the  capacity 
of  the  pelvis,  but  the  diag- 
nosis can  be  made  by  a  re- 
view of  the  clinical  symp- 
toms together  with  care- 
ful internal  and  external 
examinations.  The  pecu- 
liar pains  attendant  upon 
this  disease,  the  peculiar- 
ity of  the  gait,  and  finally 
the  total  inability  to 
walk,  the  characteristic 
beak-like  pelvis,  with  al- 
most complete  obstruc- 
tion of  the  outlet,  the  loss 
of  height,  all  make  a 
striking  clinical  picture. 
Other  types  to  be  thought 
of  in  making  the  diag- 
nosis are:  the  pseudo- 
osteomalacic,  the  Robert, 
the  kyphotic,  or  a  pelvis 
which  has  been  fractured 
or  invaded  by  malignant 
disease.  Prognosis:  It  is 
not  in  itself  a  fatal  dis- 
ease. The  patients  usu- 
ally die  of  inanition. 
The  obstruction  is  very 
marked  even  though  the 
bones  are  so  flexible.  Out 
of  85  cases  reported  by 
Litzmann,  47  were  fatal. 
Treatment:  If  taken  in 
the  beginning,  an  im- 
provement in  surround- 
ings is  indicated,  as  are 
oleum  morrhuae  and  ton- 
ics.   Phosphorus  has  been 


its  first  signal  being  rheumatoid  pains,  and  it  may  be 

This  continues  till  the  child  is  born,  after  which  the 

,  and  the  trouble  returns  at  the  next  pregnancy  and 


Fig.  849. — Large  Exostosis  of  the  Pubis. 


Fig.  850. — Exostosis  of  the  Sacral  Promontory. 


V.  ■• 

Fig.  851. — Osteosarcoma  of  the  Pelvic  Cavity. — (Bar.) 


638 


PATHOLOGICAL  LABOR. 


used.  Ovariotomy  ought  to  be  done,  especially  as  these  women  are  usually  very 
fertile.  Hysterectomy  gives  the  best  result.  Sometimes  the  suppression  of  the 
sexual  functions  may  even  cure  the  disease. 

III.  New  Growths. — The  presence  of  exostoses  or  other  kinds  of  tumors  of  the 
pelvic  bones  is  very  infrequent.  But  such  growths  may  be  the  cause  of  a  high 
degree  of  dystocia.  The  pelvis  with  bony  exostoses  (Figs.  849  and  850)  is  known 
as  acanthopelys,  acanthopelvis,  pelvis  spinosa,  spiny  or  thorny  pelvis,  and  Hau- 
der's  pelvis.  It  is  believed  that  exostoses  are  found,  as  a  rule,  in  pelves  other- 
wise deformed,  and  they  are  generally  situated  over  one  of  the  pelvic  joints.  In 
their  original  state  they  are  composed  of  cartilage,  afterward  becoming  bony. 
Most  of  them  are  small — about  the  size  of  a  small  bean  or  olive,  though  now  and 
then  they  may  attain  the  dimensions  of  a  pigeon's  egg.  In  some  cases  spicules  of 
bone  develop  at  certain  points  in  the  pelvis,  projecting  into  its  cavity.  They  are 
very  apt  to  injure  the  uterus  or  the  descending  head.  Perforation  of  the  uterus 
is  common  under  these  circumstances.  After  fracture  of  the  bones  irregular 
callus  may  also  form  projections.  Other  pelvic  tumors  are  osteosarcomata  (Fig. 
851),  enchondromata,  sarcomata,  fibromata,  cysts,  and  carcinomata.  Their  size 
will  form  the  criterion  for  the  difficulty  offered  in  labor.    The  cysts  may  be  hyda- 


FiG.    852. — Pelvis    Deformed    by    Mul- 
tiple Fractures. — {Von  Martz.) 


Fig.  853. — Pelvis  Deformed  by  Multi- 
ple Fractures. — {Paparoine  and  Tar- 
nier.) 


tid  or  may  be  formed  in  enchondromata  or  sarcomata.  Cancer  is  never  primary. 
It  may  be  an  extension  from  the  original  focus  or  it  may  be  metastatic.  The 
growth  may  infiltrate  the  bones,  making  them  porous  and  soft,  as  in  osteo- 
malacia. Prognosis:  According  to  Winckel,  in  49  cases  of  pelvic  tumor  ob- 
structing labor,  the  maternal  mortality  was  50  per  cent,  while  the  fetal  was  90 
per  cent.  Treatment:  Caesarean  section"  is  generally  performed,  although  the 
posterior  vaginal  wall  has  been  excised  and  the  growth  removed  by  this  route. 
IV.  Fractures. — Out  of  13,200  fractures  from  the  statistics  of  nine  hospitals 
in  England  and  America,  only  |  of  i  per  cent,  were  fractures  of  the  pelvis  (Hirst). 
Contracted  pelves  may  result  from  fractures  and  dislocations,  whether  con- 
genital or  occurring  later.  These  pelves  are  not  symmetrical,  and  when  the 
traumatism  has  taken  place  very  early  are  sometimes  undeveloped,  and  are 
always  accompanied  by  grave  deformity.  The  contraction  is  found  on  the  side 
of  the  fracture.  Nearly  all  cases  of  serious  pelvic  fracture  end  fatally.  The 
resulting  deformity  may  be  of  various  forms,  depending  upon  the  nature  and 
seat  of  the  fracture  (Figs.  852  and  853).  If  the  horizontal  pubic  ramus  is 
broken,  it  is  impossible  to  keep  the  broken  ends  together  during  repair,  and 
thus  great  deformity  may  result.     In  unilateral  dislocations  the  resulting  pelvis 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


639 


is   obliquely  contracted.     A   similar  deformity  is   seen   in  the  pelvis  resulting 
from  the  early  loss  of  one  leg  (Sitz  pelvis,  page  622,  Fig.  816). 

V.  Atrophy,  Caries,  and  Necrosis. — An  oblique  contraction  occurs  sometimes 
in  the  rare  event  of  tuberculosis  of  the  sacro-iliac  joint.  In  affections  of  this 
joint  there  will  develop  the  same  result  as  that  in  a  true  Naegele  pelvis  from 
imperfect  development  of  an  ala  of  the  sacrum.  If  the  trouble  takes  place  in 
early  life,  there  will  be  loss  of  substance,  arrested  development  of  the  part 
affected,  and  an  anchylosed  joint,  all  of  which  result  in  atrophy  of  the  pelvis. 


SACRO-COCCY.ART 


C.  ANOMALIES  IN  THE  JUNCTION  OF  THE  PELVIC  BONES. 

I.  Synostosis  at  the  Symphysis. — The  development  of  synostosis  in  this  joint 
is  quite  common  and  occurs  most  often  during  early  childhood.  This  condition 
would  present  a  difficulty  in  the  operation  for  symphyseotomy,  but  although 
it  would  limit  the  expansion  of  this  joint  which  normally  takes  place  during 
labor,  it  is  not  a  serious  complication  in  other- 
wise unobstructed  labor. 

II.  Synostosis  at  One  or  Both  of  the  Sacro- 
iliac Joints. — Synostosis  of  this  joint  occur- 
ring in  early  life  is  succeeded  by  badly  de- 
veloped sacral  alee  on  the  abnormal  side;  the 
part  of  the  innominate  bone  concerned  in 
this  joint  suffers  also  in  its  development,  so 
that  there  results  an  obliquely  contracted 
Naegele  type.  Arrested  development  of  the 
alae  of  the  sacrum  as  a  primary  occurrence 
is  far  more  frequently  seen  than  this  latter 
affection.  If,  instead  of  taking  place  in  early 
childhood,  the  synostosis  does  not  occur  till 
after  puberty,  the  untoward  effects  may  be 
considered  of  no  consequence.  In  case  this 
affection  takes  place  on  both  sides,  there 
results  a  pelvis  much  like  the  Robert.  This 
is  still  less  frequent  than  the  transversely 
contracted  pelvis,  owing  to  faulty  develop- 
ment of  the  sacral  alse. 

III.  Synostosis  at  the  Sacro-coccygeal 
Joint. — The  joint  between  the  sacrum  and 
the  coccyx  is  anchylosed,  as  a  rule,  between 

the  thirtieth  and  fortieth  years,  but  since  the  joint  between  the  first  and  second 
coccygeal  vertebras  does  not  take  part  in  this  process  the  effect  on  labor  is  scarcely 
worth  considering.  There  is  now  and  then  a  case  in  which  anchylosis  takes  place 
in  all  the  joints  of  the  coccyx  as  well  as  in  the  sacro-coccj^geal  joint,  especially  in 
elderly  primiparas  (Fig.  854).  If  labor  occurs  in  such  a  patient,  it  will  be  necessary 
to  fracture  the  coccyx  or  to  break  up  the  anchylosed  sacro-coccygeal  joint.  The 
fracture  sometimes  takes  place  during  the  natural  passage  of  the  head  down 
through  the  pelvic  outlet,  but  it  occurs  more  commonly  in  instrumental  delivery. 

IV.  Exaggerated  Motion  or  Separation  of  the  Pelvic  Joints. — This  may  be  just 
an  exaggeration  of  the  normal  condition  of  the  joints  during  labor.  However, 
it  will  more  probably  have  a  pathological  foundation,  such  as  inflammation 
of  the  joints,  succeeded  by  suppuration,  fluid  in  the  joint,  new  growths,  caries, 
or  osteomalacia.  During  labor  there  is  sometimes  a  predisposition  of  the  joints 
to  rupture  on  account  of  the  relaxation  incident  to  pregnancy  and  labor.     Some- 


FiG.  S54. — Anchylosis  of  the  Coc- 
cyx.—  (Author's  colleciion.) 


640  PATHOLOGICAL  LABOR. 

times  locomotion  during  pregnancy  is  made  difficult  by  the  relaxation  of  the 
joints.  (See  Part  II.)  The  coccyx  has  been  known  to  become  dislocated 
during  labor.  This  condition  is  productive  of  much  pain,  and  often  demands 
excision  of  the  bone. 

U.  ANOMALIES  OF   THE  PELVIS   DUE  TO  DISEASE  OF   THOSE  PARTS  OF  THE 
SKELETON  WHICH  ARE  CARRIED  BY  THE  PELVIS. 

I.  Spondylolisthesis.  Spondylolisthetic  Pelvis,  Kilian's  Pelvis,  Rokitansky's 
Pelvis,  Prague  Pelvis  (Figs.  855  to  860). — The  term  originated  with  Kilian,  1853, 
and  is  derived  from  spondylos  {cr-o'^du'/Mc) ^  veri;ebra,  and  olisthesis  {oMtjOeatq)^  "  a 
slipping  out  "or  "  down."  Rokitansky,  Kiwisch,  and  Seyfert;  had  described  the 
deformity,  but  Kilian  gave  the  first  accurate  description.  Neugebauer  and  Lane 
also  did  much  work  on  the  subject.  To  cause  pelvic  obstruction  spondylolisthesis 
must  take  place  in  the  lumbosacral  region,  and  in  obstetrics  we  understand  the 
term  to  indicate  a  dislocation  of  the  last  lumbar  vertebra  in  front  of  the  base  of  the 
sacrum,  so  that  the  inferior  surface,  or  possibly  the  anterior  surface  of  the  former, 
comes  in  contact  with  and  is  united  by  bony  union  with  the  anterior  surface  of  the 
first  piece  of  the  sacrum.  As  a  result  a  marked  lordosis  occurs  in  the  lumbar  ver- 
tebras, and  the  fourth,  third,  and  possibly  the  second  lumbar  vertebra  may  drop 
into  the  pelvic  inlet,  causing  an  obstruction  in  the  antero-posterior  diameter. 
Backward  and  downward  displacement  of  the  base  of  the  sacrum  and  the  poste- 
rior portion  of  the  pelvic  inlet  results.  Compensatory  elevation  of  the  anterior 
portion  of  the  pelvis  follows.  The  height  of  the  symphysis  is  increased.  Thus 
pelvic  inclination  is  markedly  lessened,  and  the  vulval  orifice  is  raised  and 
directed  more  anteriorly.  The  amount  of  obstruction  at  the  inlet  will  naturally 
depend  upon  the  distance  the  last  lumbar  vertebra  descends  and  the  degree  of 
lordosis.  Frequency  and  etiology:  It  is  not  a  common  condition.  Up  to  1892 
Schlesier  collected  fifty-three  cases  in  skeletons,  and  many  more  clinically.  It 
is  a  disease  essentially  of  women,  only  three  cases  having  been  observed  in  men. 
The  etiology  is  obscure.  It  is  caused  by  violence,  such  as  blows,  excessive  body- 
weight,  the  patients  being  commonly  obese,  and  by  the  faults  of  development  or 
ossification  in  the  articular  portions  of  the  spinal  column.  The  bones  are  often 
found  to  be  healthy.  Clinical  characteristics:  In  most  of  the  cases  the  anterior 
half  of  the  fifth  lumbar  vertebra  is  pushed  forward  at  the  same  time  that  the 
posterior  part  persists  in  its  normal  position  at  the  lumbo-sacral  joint  (Figs. 
^55'  856,  857,  858).  Now  and  then  a  case  presents  in  which  the  whole  ver- 
tebra is  pushed  forward.  There  are  some  cases  in  which  an  increased  length 
of  the  vertebra  is  caused  by  a  separation  of  the  two  extremities  of  the  spon- 
dylolytic  interarticular  part  and  the  space  is  filled  in  with  fibrous  tissue.  The 
lordosis  is  marked  (Fig.  857).  The  diminished  pelvic  inclination  causes  an 
undue  strain  on  the  ilio-femoral  ligaments.  In  this  way  the  ischial  tuberosi- 
ties are  brought  closer  together  than  normal,  while  the  crests  of  the  ilia  flare. 
Naturally  the  posterior  superior  spines  of  these  bones  flare  also.  The  ribs 
and  the  brim  of  the  pelvis  become  approximated  and  the  height  of  the 
patient  is  decreased.  The  transverse  diameter  of  the  outlet  is  diminished 
while  that  of  the  inlet  is  increased.  On  internal  examination  the  conju- 
gate diameter  of  the  inlet  may  be  observed  to  be  shortened.  Diagnosis: 
This  is  seldom  difficult.  The  patient  has  a  deformity  causing  the  distance 
from  the  costal  margin  to  the  pelvic  inlet  to  be  diminished.  There  is  marked 
lordosis  in  the  lumbar  region.  The  spine  of  the  last  lumbar  vertebra  is  more 
easily  felt  than  normally.  The  transverse  diameter  of  the  pelvis  is  increased 
owing  to  the  flaring  of  the  iliac  bones.     There  is  a  contraction  of  the  pelvic 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED  LABOR.  641 


Fig.     855. — Spondylolisthesis.       Poste- 
rior View. — {Budin.) 


Fig.  856. — Spondylolisthesis.     Anterior 
View. — {Budin.) 


Fig.  857. — Sagittal  Section  of  A'  Spon- 
dylolisthesic  Pelvis. — {Neugebauer.) 
41 


Fig.   858. — Sagittal   Section  of  a  Spon- 
DYLOLiSTHESic  Pelvis. — (Netigebouer.) 


642 


PATHOLOGICAL  LABOR. 


outlet.  The  contraction  of  the  true  conjugate  is  due  not  to  the  sacrum  but 
to  the  lumbar  vertebrae.  The  external  conjugate  is  markedly  diminished.  The 
patient  is  rather  short,  having  lost  in  stature.     Neugebauer,  in  1895,  published 


Fig.  859. — Lumbar  Vertebra  of  Nor- 
mal Shape. 


Fig. 


860. — Lumbar  Vertebra    Elongated 
BY  Spondylolisthesis. 


an  article  on   "Ichnograms"  or  pictures  of  foot -tracks.     In  spondylolisthesis 
the  steps  are  very  short,  and  the  legs,  being  converged,  are  put  forward  one  in 

front  of  the  other.    The  patient's 
appearance  and  history  are  very 
important.     There  may  be  the 
history  of  a  fall  or  other  acci- 
dent, or  the  bearing  of  heavy 
weights.     The    buttocks,  taken 
together,    are    curiously    heart- 
shaped,  being  flattened  and  end- 
ing below  in  a  point.     The  abdo- 
men   is    pendulous  and   deeply 
creased    above    the    symphysis. 
Looked  at  from  behind,  the  pa- 
tient  presents  a   saddle-shaped 
back.     Her  gait  is  peculiar;  she 
may  feel   top-heavy.     There  is 
sometimes    crepitus   in    lumbar 
region    (Fig.   855).      Prognosis: 
The  extent  of  the  obstruction  to 
labor  depends  upon  the  degree 
to  which  the  pelvic  cavity  is  en- 
croached upon   by  the  lumbar 
vertebras.    The  effect  of  this  pel- 
vis on  labor  is  similar  to  that  of 
the    fiat    pelvis.       Lacerations, 
fistulae,  and  tears  are  frequent. 
As  the  presenting  part  descends 
it  strikes  the  middle  part  of  the 
pelvic  floor  instead  of  sliding  for- 
ward to  the  orifice  of  the  vulva. 
Treatment:  A  large   proportion 
of  the  women  die  in  labor.     If 
the  deformity  is  diagnosed  and 
the  distance   from  the  nearest 
lumbar  vertebra  to  the  symphysis — the  false  or  effective  conjugate — is  2>\  inches 
(7.93  cm.),  the  forceps  can  deliver  the  child.    If  less,  a  suprapubic  operation  must 
be  done. 


Fig.  861  AND  Fig.  862. — Dorso-lumbar  Kyphosis. 
— (Tarmer.) 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED  LABOR. 


643 


Spondylolizema. — The  condition  known  as  spondylolizema  is  analogous  to 
the  one  just  described,  although  it  is  not  congenital  but  results  from  caries  of 

the  last  lumbar  veri;ebra.  The  name  pelvis  obtecta  is 
applied  to  this  deformity  as  well  as  to  the  extreme 
rachitic  pelvis. 

II.  Kyphosis,*  Kyphotic  Pelvis  (Figs.  863  to  866). 
— Breisky  gave  the  first  complete  description  of  this 
pelvis  in  1865,  although  the  condition  had  been  pre- 
viously recognized  by  Litzmann  and  Neugebauer. 
Frequency  and  etiology:  Although  this  form  of  pelvis  is 
comparatively  rare,  still  an  accurate  observer  in  the 
course  of  his  practice  will  undoubtedly  meet  with  ex- 
amples.   The  deformity  results  from  kyphosis  or  from 


"%P 


Fig.    863. — Sacro-lumbar      Fig.  864. — Kyphotic  Pelvis  showing  the  Iliac  Foss^  and 
Kyphosis.  Pelvic  Inlet. 


Fig.  865, — Diagram  of  the  Pel- 
vic Inlet  op  Fig.  864. 


Fig.    866.- 


-Kyphotic  Pelvis   showing  the   Pelvic 
Outlet. 


Pott's  disease,  which  affects  the  spine  at  such  a  low  point  that  the  usual  lordosis 
which  is  present  as  a  compensatory  factor  cannot  overcome  the  faulty  direction 

*  Kyphosis.     Hump-backed.     Angular  curvature  and  dorsal  prominence  of  the  spine. 
Backward  curvature  of  the  spinal  column. 


644 


PATHOLOGICAL  LABOR. 


Fig. 


867. — Pregnancy    with    a    Kyphotic    Pelvis. 
Hanging  Belly. — (Tarnier.) 


Fig.   868. — Oval  Oblique    Kyphotic   Pelvis. 
{Guichard.) 


of  the  force  of  the  body- 
weight.  Clinical  characteris- 
tics: Naturally  the  extent  of 
the  deformity  will  depend  on 
the  position  of  the  spinal 
protuberance  (Figs.  862,  863, 
867).  The  lower  this  is,  the 
worse  will  be  the  resulting  de- 
formity. The  most  common 
position  for  the  kyphosis  is  at 
the  junction  of  the  dorsal  and 
lumbar  vertebrae.  As  the  re- 
sult of  the  insufficient  com- 
pensation of  the  lordosis  of 
the  lumbar  spine,  the  rotation 
of  the  sacrum  on  its  trans- 
verse axis  is  downward  and 
backward,  just  opposite  to 
that  seen  in  rachitis.  The 
body  is  bent  forward,  and  the 
pelvic  inclination  diminished 
(Fig.  867).  The  sacrum  is 
higher,  straighter,  longer;  its 
lateral  concavity  is  increased 
so  that  its  width  is  lessened 
(Fig.  870).  The  conjugate  of 
the  inlet  is  increased.  The  an- 
terior spines  of  the  iliac  bones 
are  pushed  further  apart, 
while  the  posterior  spines  are 
more  closely  approximated, 
this  latter  effect  being  the  re- 
sult partly  of  the  pull  exerted 
by  the  sacro-iliac  ligaments 
and  partly  of  the  narrowness 
of  the  sacrum.  The  width 
of  the  pelvis  is  decreased 
through  its  whole  depth,  most 
markedly  so  at  the  outlet  on 
account  of  the  approximation 
of  the  spines  of  the  ischia. 
The  coccyx  and  the  end  of  the 
sacrum  are  pushed  forward, 
thus  decreasing  the  pelvic 
outlet.  The  narrower  this 
outlet  becomes,  the  wider  the 
inlet,  for  the  outward  force 
exerted  on  the  iliac  crests  is 
increased,  this  effect  being 
heightened  by  the  extra 
strain  on  the  ilio-f  emoral  liga- 
ments which  pull  the  anterior 
inferior  spines  downward  and 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


645 


Fig.  869. — Escape  of  the 
Head  under  the  Pubic 
Arch  in  a  Kyphotic 
Pelvis. — -{Tarnier.) 


outward.  In  order  that  the  body  may  not  fall  forward,  there  occurs  a  slight 
flexion  of  the  knees  and  thighs,  while  there  is  scarcely  any  pelvic  inclination  (Fig. 
862).  When  the  deformity  is  lumbo-sacral  there  may 
be  involvement  of  the  superior  part  of  the  sacrum  in 
the  pathological  process  and  its  tissues  ma^  be  de- 
stroyed (Fig.  863).  The  promontory  of  the  sacrum  is 
palpated  with  difficulty  per  vaginam.  Diagnosis:  The 
history  of  the  case  is  generally  plain,  and  the  deformity 
very  evident.  As  in  all  cases  of  pelvic  deformity,  the 
measurements  are  most  valuable.  They  show  that  the 
anterior  spines  and  crests  of  the  ilia  are  more  widely 
separated,  while  the  posterior  spines  as  well  as  the 
ischial  tuberosities  are  approximated.  The  conjugate 
of  the  outlet  is  to  some  extent  decreased.  Complica- 
tions such  as  asymmetry,  general  contraction  from 
arrested  development,  and  lateral  contraction  at  the 
inlet  should  always  be  guarded  against,  as  they  often 
make  spontaneous  labor  impossible.  Prognosis:  Winckel  states  that  in  a  series 
of  twenty-one  cases  of  this  kind  the  maternal  mortality  was  66  per  cent.,  while 

that  of  the  children  was  7  5 
per  cent.  Labor  is  much 
obstructed  by  the  promi- 
nence of  the  lumbar  spine 
in  all  cases  except  in  those 
with  the  least  marked  lum- 
bo-sacral kyphosis.  The 
untoward  effects  are  not 
generally  pronounced  until 
the  presenting  part  has 
reached  the  pelvic  floor 
(Fig.  869),  The  tendency 
to  shoulder  presentation  on 
account  of  the  decreased 
perpendicular  diameter  of 
the  abdominal  acvity  is 
generally  corrected  by  the 
first  few  labor  pains.  The 
labor  may  be  more  precipi- 
tate than  normal,  but  when 
the  presenting  part  reaches 
the  outlet  the  obstruction 
may  be  so  great  that  there 
can  be  no  spontaneous  ad- 
vance, though  now  and 
then  labor  is  terminated 
spontaneously  on  account 
of  the  great  mobilit}'-  of  the 
pelvic  joints.  Occipito- 
posterior  positions  are 
quite  common  in  these  pel- 
ves, since  on  account  of  the  posterior  deformity  of  the  sacrum  more  room  is 
offered  for  the  fetal  back.      Treatment:  As  a  rule,  labor  is  not  difficult  to  manage. 


Fig.  870. — Diagram   showing  the   Forces  Concerned 
IN  the  Production  of  a  Kyphotic  Pelvis. — {Tarnier.) 


646 


PATHOLOGICAL  LABOR. 


The  forceps  may  afford  sufficient  aid  for  delivery;  should  the  case  be  of  a  grave 
order,  symphyseotomy  will  nearly  always  suffice.    If,  however,  there  is  present  an 


^' 


Fig,  871. — Scoliosis.     Poste- 
rior View. 


Fig.  872. — Scoliotic  Pelvis,  with  Encroachment 
OF  the  Left  Cotyloid  Region  upon  the  Pelvic 
Cavity. 


Fig.  873. — Scoliotic  Pelvis.     Posterior  View.     Fig.  874. — Diagram   of  the   Pelvic 

Inlet  of  Fig.  872. 


asymmetrical  or  extreme  contraction,  it  may  be  necessary  to  resort  to  Caesarean 
section.  In  case  of  a  dead  fetus,  craniotomy  may  easily  be  performed,  since  the 
head  on  the  pelvic  floor  is  quite  accessible. 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED   LABOR. 


647 


III.  Scoliosis/'^  Scoliotic  Pelvis  (Figs.  871-874). — This  term  includes  all  the 
lateral  deformities  of  the  spinal  column  having  a  pathological  origin.  Frequency 
and  etiology:  This  is  a  rare  form  of  pelvic  deformity.  The  most  frequent  cause 
is  rachitis,  consequently  the  pelvis  may  be  contracted  as  well  as  asymmetrical. 
The  origin,  however,  may  be  non-rachitic.  The  deformity,  as  a  rule,  begins  dur- 
ing the  development  of  the  pelvis,  the  result  depending  on  whether  this  is  before 
or  after  ossification  of  the  pelvic  bones.  Clinical  characteristics :  The  deformity 
of  the  pelvis  is  marked  and  the  degree  of  scoliosis  is  quite  perceptible.  The  two 
sacrocotyloid  diameters  are  not  of  equal  length,  while  the  internal  conjugate  does 
not  come  up  to  the  nor- 
mal. Deformities  of  the 
pelvis  are  not  so  marked 
as  they  would  be,  if  every 
convexity  did  not  usually 
have  its  compensatory 
concavity.  In  the  pelvis 
with  this  deformity  there 
is  a  certain  amount  of 
oblique  contraction.  The 
lumbar  vertebrae  are  the 
ones  generally  affected. 
The  superior  articulating 
sacral  surface,  on  the  side 
toward  which  the  bending 
of  the  spine  takes  place, 
receives  the  greatest 
weight.  The  center  of 
gravity  is  displaced.  The 
head  of  the  femur  exerts 
a  greater  pressure  up- 
ward, inward,  and  back- 
ward against  the  innom- 
inate bone  of  the  de- 
formed side.  There  is 
also  an  anterior  upward 
displacement  of  the 
acetabulum  on  this  side, 
while  the  symphysis  is 
forced  to  the  opposite 
side.  The  pelvis  on  the 
deformed  side  is  dimin- 
ished  in  size  (Figs.   872, 

873,  874).  In  case  of  the  limitation  of  the  scoliosis  to  the  dorsal  vertebrae,  a 
compensatory  bending  of  the  lumbar  vertebrae  may  hinder  any  change  in  the 
form  of  the  pelvis  from  taking  place.  Diagnosis:  The  deformity  may  be  detected 
by  observation  and  pelvimetry.  Prognosis:  The  asymmetry  is  seldom  so  marked 
as  to  cause  serious  obstruction  to  labor,  the  mechanism  corresponding  with  that 
in  the  generally  contracted  pelvis.  If  delivery  is  possible,  the  forceps  is  indicated 
after  the  head  has  become  well  moulded. 

IV.  Kyphoscoliosis. t     Kyphoscoliotic    Pelvis    (Fig.    878). — This    deformity 

*  Scoliosis:  Lateral  curvature  of  the  spinal  column. 

^Kyphoscoliosis:  Backward  and  lateral  curvature  of  the  spinal  column. 


Fig.  875. — ScoLio-RACHiTic  Pelvis,  with  Reniform 
Inlet.  Encroachment  of  the  right  cotyloid  region 
upon  the  pelvic  cavity. 


Fig.  876. — Diagram  of  the   Pelvic  Inlet  of  Fig.  875. 


648 


PATHOLOGICAL  LABOR. 


includes  a  combination  of  the  malformations  of  kyphosis  and  scoliosis.  It  is 
an  obliquely  contracted  pelvis  of  lesser  degree,  being  mostly  deformed  in  the 
transverse  diameters.  Frequency  and  etiology:  The  etiology  is  naturally  that 
of  the  two  types  which  make  this  combination.  Clinical  characteristics:  The 
most  common  example  of  this  type  is  the  lumbo-dorsal  kyphoscoliosis.  The 
kyphotic  deformity  is  primary  in  point  of 
time,  and,  combined  with  the  scoliosis,  a 
combination  of  both  sets  of  deformities  re- 


Sc.prdr 


Sc.o. 


Fig.  877. — ScoLio-RACHiTic  Skeleton.  Sc.pr.dr., 
Primary  dorsal  scoliosis;  Sc.o.l.g.,  compensatory 
lumbar  scoliosis. — (Clamart.) 


Fig. 


878. — Kyphoscoliotic   Skele- 
ton.— (Leopold.) 


suits  with  a  trace  of  the  original  funnel-shape.  The  pelvis  is  decidedly  asym- 
metrical, though  its  lateral  contraction  is  not  so  great  as  in  a  pure  kyphosis.  As 
the  kyphosis  is  etiologically  rachitic  and  not  carious,  it  will  not  be  angular,  but 
it  will  be  superior  dorsal  in  position  and  will  run  the  chance  of  being  compensated 
for  by  lordosis  of  the  lumbar  region.  The  joints  are  all  rachitic.  The  symphysis 
is  inclined  to  the  side  opposite  the  direction  of  the  lumbar  curve.     The  spinal 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED   LABOR. 


649 


bones  present  the  combined  deformities  of  rachitis  and  kyphosis.  Vaginal  exam- 
ination yields  the  same  results  as  in  kyphosis.  The  true  conjugate  is  increased 
and  the  pelvis  is  transversely  flattened  and  represents  a  lesser  degree  of  obliquely 
contracted  pelvis.  Diagnosis :  This  will  be  made  from  observation  of  the  deformity 
and  from  pelvic  measurements.  Prognosis:  This  will  depend 
upon  the  degree  of  deformity. 

V.  Assimilation  Pelvis. — This  pelvis  resembles  the  ky- 
photic type  and  is  slightly  funnel-shaped.  The  deformity 
depends  upon  the  symmetrical  blending  of  the  five  vertebrae 
of  the  coccyx  with  the  lower  sacral  vertebra  or  of  the  upper 
sacral  vertebra  with  the  lower  lumbar  vertebra  (Fig.  879). 
Single-sided  asymmetry  may  depend  upon  scoliosis  of  the 
vertebras  of  the  coccyx.  The  deformity  then  resembles 
scoliosis  and  is  more  pronounced  in  the  presence  of  rachitis. 
When  the  deformity  is  symmetrical,  the  promontory  is  high, 
the  angle  being  but  slightly  developed,  and  the  pelvic  curve 
diminished  by  the  slight  forward  bending  of  the  trunk. 

VI.  Lordosis  Pelvis.* — Neugebauer  refers  to  some  cases 
of  primary  lordosis  independent  of  spinal  disease  or  pelvic 
deformity,  and  in  this  country  the  only  case  described  is  that 
of  Hirst  (Fig.  880).  It  can  readily  be  seen  how  a  marked 
anterior  spinal  curvature  would  greatly  increase  the  pelvic 
inclination,  and  thus  interfere  with  the  engagement  of  the 
presenting  part. 


Fig.  879. — Assimilation  of  the  First  Coccygeal  Vertebra  with 
THE  Sacrum,  i,  Blending  of  the  horns  of  the  coccyx  and  sa- 
crum; 2,  blending  of  the  bodies  of  the  fifth  sacral  and  first 
coccygeal;  3,  movable  intercoccygeal  articulation;  4,  assimilation 
of  first  coccygeal  vertebra;  5,  coccyx. 


Fig.  880. — Lordo- 
sis FROM  Pa- 
ralysis OF  the 
Spinal  Muscles. 
—{Hirst.) 


E.  ANOMALIES  OF  THE   PELVIS  DUE  TO  DISEASE  OF  THE  WEIGHT-BEARING 

PARTS  OF  THE  SKELETON. 

I.  Coxitis.  Coxalgic  Pelvis  (Fig.  883). — This  deformity  may  be  described  as 
an  oblique  pelvis  dependent  upon  hip  disease.  The  coxalgic  pelvis  is  subject 
to  several  modifications  which  depend  upon  the  time  at  which  the  affection 
originates  and  the  mobility  of  the  diseased  part  as  well  as  upon  the  presence  of 
dislocation.  The  earlier  this  trouble  begins  and  the  more  the  leg  is  used,  the 
greater  will  be  the  deformity.  If  the  disease  does  not  appear  till  after  the  pelvis 
*  Lordosis:  Anterior  curvature  of  the  spinal  column. 


650 


PATHOLOGICAL  LABOR. 


is  developed,  there  may  be  an  absence  of  obliquity.  Frequency  and  etiology:  The 
deformity  is  not  infrequent.  Other  causes  besides  hip-disease  are  infantile  par- 
alysis, dislocation  of  the  hip-joint,  and  amputation  of  a  lower  extremity.  Clini- 
cal characteristics:  There  are  two  types  of  this  pelvis,  although  there  is  obliquity 
in  each  case:  (i)  In  the  first  type  the  innominate  bone  on  the  unaffected  side  is 
pushed  upward,  inward,  and  backward,  since  the  sound  leg  carries  the  main  body- 
weight  (Fig.  88i).  Thus  the  sound  side  is  contracted  while  the  diseased  side, 
lacking  the  normal  developing  forces,  persists  in  its  infantile  form  or  the  form  it 
had  when  the  disease  manifested  itself.  The  location  of  the  deformity  is  just 
the  reverse  of  that  in  the  Naegele  pelvis.  (2)  In  the  other  type  the  deformity 
is  on  the  diseased  side,  the  innominate  bone  of  this  side  being  forced  in  upon  the 
pelvis,  the  deformity  depending  upon  the  arrested  development  of  this  side  (Fig. 
882).  There  is  probably  a  co-existent  atrophy  of  the  sacral  ala  with  anchylosis 
of  the  sacro-iliac  joint.  There  will  be  observed,  therefore,  an  asymmetrical  pelvis ; 
rotation  of  the  pelvis  upon  the  spinal 
column;  anchylosis  of  the  hip  and 
decided  shortening  of  the  conjugate. 


Fig.  881. — CoxALGic  Pelvis  showing  De- 
formity ON  THE  Healthy  Side. 


Fig.  882. — CoxALGic  Pelvis  showing  De- 
formity ON  the  Diseased  Side. 


Diagnosis:  These  patients  are  recognized  by  their  limp.  Pelvimetry  as  well  as 
palpation,  both  external  and  internal,  will  reveal  the  state  of  affairs  in  the  pelvis. 
Prognosis:  The  degree  of  deformity  is  seldom  so  great  as  to  interfere  seriously 
with  labor.  In  such  a  case  the  method  of  procedure  would  correspond  with  that 
advised  for  the  Naegele  pelvis.  In  the  first  type  there  is  seldom  any  serious 
obstruction  to  labor  unless  rachitis  is  also  a  complication.  It  is  in  the  second 
type  that  difficulty  is  experienced,  and  it  may  be  as  great  as  in  the  Naegele 
form. 

II.  Luxation  of  the  Head  of  One  Femur  (Figs.  885,  886). — If  this  deformity 
is  congenital  or  if  it  take  place  in  early  years,  the  pelvis  is  somewhat  affected, 
but  not,  as  a  rule,  to  such  an  extent  as  to  affect  labor  seriously.  The  resulting 
shape  of  the  pelvis  will  depend  upon  the  direction  in  which  the  luxation  takes 
place.     An  oblique  contraction  may  be  produced  by  a  one-sided  dislocation. 

III.  Luxation  of  the  Heads  of  Both  Femora  (Figs.  887,888,  889,  890). — The 
general  statements  made  in  the  last  paragraph  will  also  apply  to  this  case.     If 


MATERNAL  DYSTOCIA    FROM  OBSTRUCTED   LABOR,  651 


both  thigh-bones  are  dislocated  backward  upon  the  ilia,  the  sacrum  is  rotated 

forward  to  an  extreme  degree, 
and  the  canal  of  the  pelvis  be- 
comes shallow  with  a  very  wide 
outlet.  The  line  between  the 
lower  border  of  the  symphysis 
and  the  inner  femoral  condyle 
is  diminished. 


Fig.  883. — CoxALGic  Pelvis  with  Adduction  of 
THE  Diseased  Femur  (Left  Side). 


Fig.  884. — Enlargement  of  the 
Cotyloid  Region  due  to  Cox- 
algia. 


IV.  Unilateral  or  Bilateral  Club-foot  (Fig.  891). — These  deformities  produce 
changes  of  little  importance.  The  inclination  of  the 
pelvis  is  increased,  the  arch  of  the  pubis  is  narrowed, 
the  tuberosities  of  the  ischia  and  the  acetabula  are 
brought  closer  together. 

V.  Absence  or  Deformity  of  One  or  Both  Lower 
Extremities. — In  the  first  case  there  results  the  "Sitz 
pelvis,"  the  characteristics  of  which  have  already  been 
noted  (page  622).     Generally  there  is  rotation  of  the 


Fig.  885. — Dislocation  of      Fig.  8S6. — Deformed  Pelvis  from  Congenital  Disloca- 
THE  Right  Femur.  tion  of  One  Femur  (Left  Side). 


652 


PATHOLOGICAL  LABOR. 


innominate  bones  on  an  anteroposterior  axis,  so  that  the  iliac  crests  approach 
each  other,  while  the  ischial  tuberosities  are  separated.  Any  deformity  occurring 
in  consequence  of  the  bowing  of  the  extremities  is  scarcely  worth  the  mention 
from  a  practical  standpoint. 

GENERAL  SYMPTOMATOLOGY. 

Subjective  Symptoms. — In  pregnancy:  The   effects  of   deformed  pelves  are 
various.     They  may  alter  the  position  of  the  pregnant  uterus ;  e.g.,  in  contraction 


Fig.    887. — Congenital   Dislocation   of 
Both  Femurs. 


Fig. 


-Congenital    Dislocation    of 
Both  Femurs. 


of  the  pelvic  inlet  in  the  early  months,  the  uterus  may  become  retroverted,  and 
even  finally  incarcerated  in  the  pelvis.  Later  the  uterus  is  higher  than  in  normal 
gestation,  since  the  head  of  the  fetus  cannot  descend  into  the  pelvis.  In  the 
later  months  of  pregnancy  the  uterus  is  far  more  mobile  than  normal  on  account 
of  the  narrowing  of  the  pelvis.  Its  obliquity  is  also  increased.  The  patient  is 
frequently  unable  to  empty  the  bladder  owing  to  the  pressure  to  which  it  is 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


G53 


subjected.  Quickening  is  felt  early,  generally  by  the  fourth  month.  Pendulous 
abdomen  is  very  common  in  contracted  pelvis  from  the  position  of  the  long  axis 
of  the  uterus,  which  looks  either  forward  or  to  the  right,  and  is  especially  marked 
in  patients  whose  abdominal  walls  are  flaccid.     It  is  more  frequently  found  in 

multigravidae  than  in  primigra- 
vidae.  If  pendulous  abdomen  is 
not  a  complication,  the  fundus 
will  be  much  higher  in  position 
than  normal.  In  labor:  The  pains 
are  very  irregular  and  their  nature 
depends  upon  the  abnormal  fac- 


FiG.  889. — Pelvis  from  a  Case  of  Congenital 
Dislocation  of  Both  Femurs. 


Fig. 


890. — Diagram  of  the  Pelvic 
Inlet  of  Fig.  889. 


tors  producing  them.  They  are  sometimes  violent,  at  other  times  spasmodic,  and 
again  they  are  feeble.  Labor  is  prolonged.  When  labor  is  beginning,  the  pre- 
senting part  is  abnormally  high  and  does  not  adapt  itself  well  to  the  lower  uterine 
segment.  The  head  is  very  slow  in  engaging,  consequently  in  pregnancy  lightening 
does  not  occur,  and  these  conditions 
give  rise  to  painful  dyspnea.  Some- 
times the  presenting  part  fails  to 
engage  at  all.  The  caput  succeda- 
neum  is  generally  very  large  and  its 
gradual  development  is  sometimes 
thought  to  indicate  progress  of  the 
descending  part.  The  presentation 
and  position  of  the  fetus  also  often 
suffer  from  contracted  pelves,  the 
abnormal  varieties  being  about  three 
times  as  common  as  normal.  For 
example,  a  vertex  presentation  may 
be  turned  into  a  brow,  face,  or  shoul- 
der. In  breech  presentation  there  is 
frequently  a  prolapse  of  foot  or  knee. 
Prolapse  of  the  cord  is  also  frequent. 
Multiparity,  as  in  the  normal  pelvis, 

only  adds  to  the  likelihood  of  faulty  presentations,  for  the  walls  of  both  uterus 
and  abdomen  became  gradually  more  relaxed  with  each  successive  pregnancy. 
If  the  uterus  together  with  the  cervix  is  either  at  or  above  the  pelvic  inlet,  the 
bag  of  waters  is  forced  downward  into  the  cervix  as  a  conical  body 


Fig. 


Deformed  Pelvis    from    Double 
Club-foot. 


Not  infre- 


Fig.  S92. 


Fig.  S93. 


Fig.  894. 


Fig.  895. 


Fig.  896. 


Fig.  897. 


Fig.  898. 

Figs.  892  to  898. — Shape  of  the  Pelvic  Inlet  in  the  More  Common  Types  of 
Pelvic  Deformity,  Compared  with  the  Normal. 


654 


MATERNAL  DYSTOCIA  FROM  OBSTRUCTED   LABOR.  655 

quently  the  membranes  rupture  early  with  escape  of  the  liquor  amnii.  The  lower 
uterine  segment  may  become  so  stretched  and  thin  that  it  bursts,  while  the  rup- 
ture may  involve  the  cervix  and  vagina  or  there  may  occur  a  forcible  separation 


Fig.    899.— Congenital  Fig.  900.— Osteo-  Fig.  901.— Rachitis.  Rela-         Fig.  902. — Oval  Oblique 

Dislocation  OF  Both  malacia.  tively  Contracted.  Pelvis. 

Femurs. 

Figs.  899  to  902. — The  Author's  Lead-tape  Tracings  of  Various  Types  of  Pelvic 
Deformity,  showing  Sagittal  Sections  and  Shapes  of  the  Pubic  Arches  of  Each. 

of  the  uterus  from  the  vagina.     In  any  case  the  maternal  soft  parts  are  apt  to  be 
bruised  and  lacerated;  so  much  so,  indeed,  that  sloughing  will  often  follow. 


Fig.  903.— Double  Oblique     Fig.  904.— Spontaneous        Fig.  905.— Rachitis.  Abso-         Fig.     906.  —  Oval 
Pelvis  Dislocation   of   One  lutely  Contracted.  Oblique  kypho- 

Femur.  tic  Pelvis. 

Figs.  903  to  906. — The  Author's  Lead-tape  Tracings  of   Various  Types  of  Pelvic 
Deformity,  showing  Sagittal  Sections  and  Shapes  of  the  Pubic  Arches  of  Each. 


(Edema  is  also  a  complication.     The  articulations  are  in  certain  cases  separated 
by  the  force  exerted  for  the  delivery  of  the  child. 

Objective   Symptoms. — (See  General  Diagnosis,  below.)     (Figs.  892  to  906.) 


656  PATHOLOGICAL  LABOR. 


GENERAL  DIAGNOSIS. 

Previous  History. — The  previous  history  will  often  furnish  essential  infor- 
mation concerning  the  present  condition  of  the  pelvis.  If  traces  of  rachitis, 
for  example,  are  seen  in  other  parts  of  the  body,  there  will  be  strong  presumptive 
evidence  as  to  the  presence  of  a  rachitic  pelvis.  The  history  of  previous  labors 
will  offer  a  probable  prognosis  as  to  the  termination  of  pregnancy.  The  char- 
acteristic influences  of  the  various  diseases  have  been  enumerated. 

Inspection. — Account  should  be  taken  of  the  posture  of  the  woman,  of  spinal 
curvature,  and  of  any  lameness. 

Palpation. — The  position  of  the  hips,  the  size  of  the  iliac  bones,  the  depths 
of  the  iliac  fossse,  the  width  and  curve  of  the  sacrum,  and  the  depth,  thick- 
ness, and  inclination  of  the  symphysis  should  be  noted  (Figs.  892  to  906). 

Mensuration.  Pelvimetry. — The  physician  should  measure  the  pelvis  as  a 
routine  in  the  examination  of  pregnancy  (see  page  148)  and  in  cases  of  suspected 
maternal  or  fetal  obstruction,  for  the  same  reason  that  he  uses  percussion 
and  auscultation  in  the  diagnosis  of  cardiac  and  pulmonary  disease.  Al- 
though the  science  of  pelvimetry  is  most  important,  still  the  child's  birth  de- 
pends partly  on  the  size  of  its  head,  the  degree  of  its  adaptability,  the  char- 
acter of  the  uterine  contractions,  and  the  resistance  of  the  maternal  perineum 
and  soft  parts.  It  also  happens  that  in  two  patients  with  the  same  size  pelves  one 
can  be  delivered  spontaneously  while  the  other  cannot.  However,  these  facts 
do  not  lessen  the  obstetrician's  duty  in  respect  to  pelvimetry;  they  merely  indi- 
cate its  limitations.  (Compare  clinical  characteristics  of  various  forms  of  pelvic 
deformity,  pages  619  to  653.) 

Prognosis, — (See  Individual  Varieties  and  Treatment.) 

PROPHYLACTIC  TREATMENT. 

Prophylaxis  may  be  instituted  at  various  stages  in  the  history  of  the  mother. 

In  case  of  the  grosser  pelvic  deformities,  seen  before  marriage,  in  which  birth 
by  the  natural  passages  would  be  impossible,  one  would  be  justified  in  advising 
celibacy. 

If  a  woman  with  a  pelvis  which  will  not  permit  the  birth  of  a  viable  child  is 
already  married,  or  if  the  pelvis  of  a  newly  married  woman  is  contracted  to  a 
questionable  degree  and  the  husband  is  of  another  race,  or  much  larger  than  his 
wife,  or  has  head  measurements  unlike  hers,  it  may  be  advisable  to  avoid  concep- 
tion. In  any  case  the  choice  must  lie  between  foregoing  offspring  altogether  and 
conception  with  some  expedient  for  avoiding  labor  at  full  term.  If  the  woman 
conceives  deliberately,  much  care  should  be  used  in  determining  as  accurately  as 
possible  the  date  of  the  fecundating  coitus.  The  subject  of  avoidance  of  concep- 
tion has  been  considered  on  page  37.  kr.  Is-  ^-m--\ 

In  cases  of  absolute  contraction  seen  after  conception  has  occurred,  much 
would  depend  upon  the  month  of  gestation  at  which  the  advice  of  the  physician 
is  sought.  If  the  pregnancy  is  recent  and  the  pelvis  such  that  natural  delivery 
would  be  impossible,  the  alternative  is  between  artificial  abortion  and  Caesarean 
section  at  term.  In  this  situation  the  burden  of  choice  should  be  placed  on  the 
woman  and  her  relatives.  If  Caesarean  section  is  absolutely  refused,  pregnancy 
may  be  interrupted — the  sooner  the  better.  In  anything  short  of  absolute  pelvic 
contraction,  artificial  abortion  would  not  be  justifiable.  If  the  pregnancy  were 
far  advanced  in  absolute  pelvic  stenosis,  little  or  nothing  would  be  gained  by 
the  induction  of  premature  labor  in  comparison  with  Caesarean  section.  In 
instances  of  relative  contraction,  the  patient,  whatever  the  stage  of  pregnancy, 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED   LABOR.  657 

may  look  forward  to  a  twofold  alternative:  (i)  Artificial  premature  delivery; 
(2)  delivery  at  full  term  with  dependence  upon  Prochownik's  diet  to  keep  down 
the  size  of  the  fetal  head,  (i)  Artificial  premature  labor:  This  is  a  preventive  of 
dystocia,  the  only  objection  being  the  danger  of  fetal  death  from  immaturity. 
As  to  the  mother,  the  danger  is  undoubtedly  greater  in  dystocic  delivery  than  in 
induced  labor.  (2)  Diet:  The  principle  of  regulating  the  diet  of  the  pregnant 
woman  for  the  purpose  of  preventing  overgrowth  or  retarding  full  development 
on  the  part  of  the  fetus,  and  thereby  favoring  eutocia,  has  been  carried  out  in  a 
limited  way  for  a  number  of  generations;  yet  this  topic  is  hardly  mentioned  in 
the  great  majority  of  text-books. 

Prochownik's  attention  was  called  to  the  subject  by  the  mortality  among 
children  bom  before  term,  especially  in  connection  with  induced  labor  for 
contracted  pelvis;  and  by  his  special  experience  in  dieting  pregnant  women 
who  were  obese,  anemic,  etc.,  with  the  sole  aim  of  improving  the  mother.  In 
this  connection  he  found  that  the  nutrition  of  the  fetus  was  modified  in  a  twofold 
manner:  first  the  embryo  was  enough  of  a  true  parasite  to  obtain  nutriment  to 
fulfil  all  the  practical  ends  of  healthy  metabolism,  growth,  and  vitality;  second, 
the  restriction  in  the  mother's  diet  could  manifest  itself  in  the  child  in  such  par- 
ticulars as  a  lessened  accumulation  of  adipose  tissue,  and  a  slower  rate  of  precipita- 
tion of  the  earthy  matter  required  for  ossification.  Observations  of  this  char- 
acter have  been  reduced  to  a  common  truth  in  biology  and  the  application  of  the 
diet  to  women  with  contracted  pelves  as  a  substitute  procedure  for  artificially 
induced  premature  labor  was  a  consistent  and  logical  advance  in  the  management 
of  obstructive  maternal  dystocia.  One  of  the-  first  problems  in  imposing  this 
diet  upon  the  pregnant  woman  is  to  cut  down  the  amount  of  fluids  without  the 
collateral  provocation  of  constant  thirst.  To  this  end  fats  and  carbohydrates 
are  eliminated  as  far  as  possible  and  such  articles  are  allowed  as  contain  a  large 
quantity  of  water,  especially  green  vegetables.  The  diet  *  as  originally  published 
appears  to  have  stood  the  test  of  experience  without  the  necessity  of  subsequent 
modification.     It  is  as  follows : 

Breakfast. — A  small  cup  of  black  coffee,  3.38  oz.  (100  c.c);  zwieback,  or 
bread  with  a  little  butter,  4  or  5  oz.  (25  grams). 

Luncheon. — Any  kind  of  meat  or  fish,  eggs,  green  vegetables,  salad,  cheese. 

Dinner. — Same  as  luncheon,  with  the  addition  of  bread  and  butter  i  to  ij 
oz.  (40  to  50  grams). 

Absolutely  Forbidden. — Water,  soup,  potatoes,  farinaceous  food,  sugar,  beer. 
Fluids  allowed:  10  to  14  oz.  (300  to  400  c.c.)  red  or  Moselle  wine  or  water  per  diem. 

Prochownik  has  now  employed  this  diet  for  the  past  twelve  years,  the  total 
number  of  births  aggregating  26,  while  other  obstetricians,  especially  in  the 
Netherlands,  have  brought  the  total  up  to  62. 

An  analysis  of  the  material  which  is  tabulated  by  Prochownik  in  the  "  Therapeutische 
Monatschrift,"  August  and  September,  1901,  appears  to  establish  the  truth  of  the  following: 
(i)  All  the  mothers  bore  the  diet  well  after  slight  initial  hardships,  principally  thirst  (espe- 
cially in  the  corpulent) ,  and  repugnance  to  so  much  animal  food.  Both  these  difficulties 
were  mitigated  by  increasing  the  allowance  of  green  vegetables.  The  weight  of  the  woman, 
allowance  being  made  for  the  growth  of  the  embryo  and  uterus,  remained  practically  at  a 
standstill.  (2)  All  the  confinements  were  relatively  easy  in  comparison  with  previous  labors, 
even  in  those  exceptional  cases  in  which  despite  the  diet  the  fetus  was  large  and  fat  at 
birth.  (3)  All  the  children  were  bom  alive,  although  the  mothers,  as  a  class,  had  expe- 
rienced still-births.  The  few  cases  of  asphyxia  neonatorum  were  easily  reanimated.  As 
far  as  known,  all  the  children  survived  the  accidents  which  produce  secondary  mortahty. 
(4)  The  great  majority  of  the  children  were  lean  at  birth,  there  being  a  notable  subdevelop- 
ment  of  the  panniculus  adiposus.  The  skin  of  the  head  was  noticeably  lax  and  the  cranial 
bones  exhibited  a  notable  degree  of  mobility  upon  one  another.      (5)  The  children  exhibited 

*  "Centralbl.  f.  Gynak.,"  1SS9,  No.  2>i- 
42 


658  PATHOLOGICAL  LABOR. 

the  essential  insignia  of  maturity  (normal  length,  head  measurements,  etc.).  (6)  The  nor- 
mal gain  in  weight  took  place  in  the  majority  of  the  children.  (7)  The  diet  of  the  mother 
exerted  no  unfavorable  influence  upon  lactation. 

Naturally,  as  soon  as  delivery  occurs  the  special  diet  is  discontinued  and 
the  substitute  regimen  is  rich  in  non-nitrogenous  articles.  In  all  attempts 
at  imposing  an  antidystocic  diet  upon  a  pregnant  woman  the  regimen  is  not  to 
be  begun  until  the  latter  months  of  pregnancy.  The  Prochownik  regimen  is 
intended  for  the  last  six  weeks  of  gestation  only.  It  is  believed  that  no  extra 
advantage  would  accrue  from  lengthening  the  dietetic  period.  The  large  propor- 
tion of  nitrogenous  food  and  the  small  quantities  of  fluid  of  Prochownik's  diet 
undoubtedly  favor  the  toxemia  of  pregnancy.  I  was  confronted  with  this  difh- 
culty  in  a  relative  generally  contracted  pelvis,  and  in  spite  of  the  free  exhibition 
of  calomel  and  colon  irrigation  was  compelled  to  abandon  the  diet,  and  to  induce 
labor  at  the  thirty-eighth  week. 

CURATIVE  TREATMENT. 

The  problem  of  the  proper  management  of  labor  in  contracted  pelves  is  one 
of  the  most  difficult  in  midwifery.  The  subject  itself  is  a  vast  one,  for  it  con 
cerns  not  only  those  cases  in  which  the  pelvis  has  been  measured  and  the  pelvic 
anomaly  diagnosticated,  but  that  greater  contingent  in  which  no  exact  pelvic 
diagnosis  is  made  and  which  simply  represents  obstructive  dystocia  from  some 
cephalo-pelvic  disproportion  which  is  generally  of  maternal  origin.  Broadly 
speaking,  these  labors  can  be  managed  in  three  ways:  (i)  Pregnancy  may  be 
interrupted  before  the  fetus  has  attained  a  certain  size  (Part  X).  (2)  Labor 
at  term  may  be  managed  along  normal  lines;  i.  e.,  may  be  left  to  nature  until 
some  complication  arises  which  threatens  the  lives  of  mother  and  fetus.  (3) 
Some  form  of  active  intervention,  undertaken  for  the  purpose  of  protecting  the 
mother  and  child  from  the  risks  of  dystocia,  may  be  practised  at  or  before  the 
onset  of  labor — or  forceps,  symphyseotomy,  embryotomy,  or  Cassarean  section. 

It  is  a  singular  fact  that  precedent  and  local  prejudice  play  highly  important 
roles  in  the  choice  of  methods.  Thus,  in  one  obstetrical  center  perforation  of 
the  fetal  cranium  appears  to  be  the  commonest  termination  of  these  labors;  in  a 
second,  the  ideal  is  symphyseotomy;  in  a  third,  expectancy  predominates;  in  a 
fourth,  induction  of  premature  labor.  Those  obstetricians  who  follow  the  national 
or  local  custom  in  the  management  of  these  cases  naturally  offer  reasons  for  their 
conduct  which  appear  sufficient  for  its  justification.  In  many  localities  adherence 
to  routine  and  precedent  is  responsible  for  unnecessary  mortality  and  morbidity, 
either  fetal  or  instrumental. 

Some  authorities  who  are  not  under  the  influence  of  custom  are  actuated 
largely  by  theoretical  considerations  in  the  management  of  these  labors.  Their 
theories  may  be  the  outgrowth  of  personal  experience.  Thus,  an  obstetrician  who 
has  seen  spontaneous  labor  occur  repeatedly  in  moderately  contracted  pelves 
without  undue  prolongation  of  the  act  of  parturition  comes  to  believe  that  such 
pelves  up  to  a  certain  limit  are  not  pathological  at  all.  He  therefore  adopts  a  let- 
alone  policy  in  the  management  of  these  cases.  Another  practitioner  may  have 
seen  some  accident — a  rupture  of  the  uterus,  perhaps — occur  in  a  pelvis  with  but 
a  slight  degree  of  narrowing.  Thenceforth  pelvic  contraction  is  always  something 
to  be  feared,  and  he  forms  a  rule  of  terminating  such  pregnancies  by  the  induction 
of  premature  labor  or  Csesarean  section. 

Many  obstetricians  try  to  formulate  indications  for  treatment  based  upon  the 
length  of  the  trite  conjugate  as  a  clinical  index  of  pelvic  contraction  and  the  par- 
ticular species  of  pelvic  deformity.     But  even  if  a  uniform  scale  were  agreed  upon, 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR. 


659 


this  method  of  fixing  indications  is  trustworthy  only  to  a  certain  extent;  viz.,  in 
determining  absolute  pelvic  contraction,  or  the  degree  which  is  prohibitive  of 
delivery  by  natural  passage  at  term.  This  *  is  represented  in  a  flat  pelvis  by  a 
true  conjugate  of  less  than  2.76  inches  (7  cm.),  and  in  a  generally  contracted  pelvis 
by  a  true  conjugate  of  less  than  2. 95  inches  (7. 5  cm.).  Other  obstetricians  make  the 
degree  of  absolute  contraction  slightly  lower  or  higher,  but  the  statistics  of  Kronig  t 
show  conclusively  that  a  goodly  proportion  of  labors  may  be  spontaneous  through- 
out, in  any  degree  of  pelvic  narrowing  which  is  outside  the  limit  of  absolute  pelvic 
contraction.  The  same  statistics  show  that  interference  may  sometimes  be  indicated 
in  the  very  mild  degree  of  contraction.  There  is  no  criterion  by  which  the  obstet- 
rican  may  foretell  the  outcome  of  a  case.  In  something  like  6  per  cent,  of  cases  of 
labor  in  contracted  pelves,  irrespective  of  the  pelvic  measurements,  labor  could 
not  be  completed  without  resort  to  Csesarean  section,  symphyseotomy,  or  embryo- 
tomy. It  is  fair  to  assume  that  in  this  minority  of  cases  there  was  either  absence 
of  proper  pains  or  defective  head  moulding,  and  that  these  elements  rather  than 
a  particular  degree  of  pelvic  contraction  were  chiefly  responsible  for  the  dystocia. 
In  other  words,  given  sufficient  plasticity  of  the  head  and  strong  uterine  contrac- 
tions, relative  contraction  of  the  pelvis  does  not  necessarily  mean  dystocia.  In 
other  words,  the  difference  in  the  length  of  the  true  conjugate,  up  to  a  certain 
point,  does  not  furnish  a  basis  for  special  indications.  Other  factors  are  present  in 
sufficient  force  to  invalidate  any  system  of  procedure  based  upon  several  degrees 
of  pelvic  narrowing.  A  division  into  two  degrees  is  well  and  good,  for  the  indi- 
cations in  absolute  and  relative  contraction  differ  widely;  and  although  the  sub- 
division of  the  relative  contractions  in  two  classes  is  not  always  satisfactory, 
it  is  most  convenient  and  the  best  method  we  have  for  purposes  of  classification 
and  clinical  study. 


CLASSIFICATION  OF  PELVIC  CONTRACTION. 


Absolute  Pelvic 
Contraction. 


Relative  Pelvic 
Contraction. 


Simple  flat  pelvis  with  a  true  conjugate  of  less  than  2.76  inches 

(7  cm.) 
Generally  contracted  pelvis  with  a  true  conjugate  less  than  2.95 

inches  (7.5  cm.) 

(Class  One. — First  Degree  Coniraciion 
— Simple  flat   pelvis  with  a   true 
conjugate    from    3.74    inches   (9.5 
cm.)  to  3.35  inches  (8.5  cm.) 
Generally   contracted  pelvis  with   a 
true   conjugate  from  4  inches   (10 
cm.)  to  3.60  inches  (9  cm.) 
Class   Two. — Second  Degree  Contrac- 
tion.— Simple  flat  pelvis  with  a  true 
conjugate  of  from  3.35  inches  (8.5 
cm.)  to  2.75  inches  (7  cm.) 
Generally  contracted  pelvis  with   a 
true  conjugate  of  from  3.50  inches 
(8.9  cm.)  to  2.95  inches  (7.5  cm.) 


i  Simple  flat  pelvis  with  a 
true  conjugate  of  2.76 
inches  (7  cm.)  or  more. 
'  Generally  contracted  pelvis 
with  a  true  conjugate  of 
2.95  inches  (7.5  cm.)  or 
more. 


I.  ABSOLUTE  PELVIC  CONTRACTION. 

An  absolutely  contracted  pelvis  is  represented  in  a  simple  flat  pelvis  by  a 
true  conjugate  of  less  than  2  76  inches  (7cm.),  and  in  a  generally  contracted' 
pelvis  by  a  true  conjugate  of  less  than  2.95  inches  (7.5  cm.).      If  a  woman  with 
absolute  pelvic  contraction  becomes  pregnant,  and  is  seen  in  season,  she  should 
be  allowed  to  choose  between   therapeutic   abortion  and  Cassarean  section  at 

*  Kronig:   "  Die  Therapie  beim  engen  Becken,"  Leipzig,  1901.  t  Loc.  cit. 


660  PATHOLOGICAL   LABOR. 

term.  If  she  be  seen  before  the  end  of  the  seventh  month  it  may  be  possible 
to  induce  labor  and  perform  craniotomy. 

In  this  situation,  the  burden  of  choice  should  be  placed  on  the  patient  and 
her  family;  of  other  alternatives,  it  is  not  worth  while  to  speak. 

My  experience  with  symphyseotomy  would  cause  me  to  emphatically  reject 
the  claim  of  the  Italian  school  that  this  operation  has  a  place  either  in  induced 
premature  labor  at  or  after  the  seventh  month,  or  at  the  fortieth  week  in  ab- 
solutely contracted  pelves. 

Again  perforation  and  embryotomy  are  possible  at  term  in  the  above  cases, 
but  I  am  satisfied  that  the  mortality  is  greater  than  in  Caesarean  section. 

Some  English  authorities  and  J.  W.  Williams  advise  that  if  the  true  con- 
jugate be  above  two  inches  (5  cm.)  (absolute  indication  for  Caesarean  section 
of  some  authorities),  craniotomy  should  be  the  operation  of  choice  when  the 
fetus  is  dead  or  dying. 

From  this  I  strongly  dissent,  as  my  experience  with  craniotomy  in  these  low 
grades  of  pelvic  deformity  has  taught  me  that  they  carry  with  them  a  high 
degree  of  mortality  to  the  mother.  Moreover,  unsuccessful  attempts  at  cranio - 
clast  extraction  and  at  embryotomy  in  pelves  whose  clinical  index  is  between 
2  and  2^  inches,  will  greatly  militate  against  the  chances  of  the  patient's  recov- 
ery from  a  Csesarean  section  that  is  subsequently  necessary  to  deliver  her. 


2.  RELATIVELY  CONTRACTED  PELVES. 

A  relatively  contracted  pelvis  is  represented  in  a  simple  flat  pelvis  by  a 
true  conjugate  of  2.76  inches  (7  cm.)  or  more  and  in  a  generally  contracted 
pelvis  by  a  true  conjugate  of  2,95  inches  (7.5  cm.)  or  more. 

Relative  contraction  of  the  pelvis  does  not  necessarily  cause  dystocia.  Thus, 
statistics  show  that  a  great  majority  of  labors  in  all  degrees  of  relatively 
contracted  pelves  may  be  termed  physiological.* 

*  The  Kronig  statistics  of  the  latter  (loc.  cit.)  show  that  of  504  cases  of  labor  in  flattened 
pelves  with  a  true  conjugate  between  3.74  and  2.76  inches  (9.5  and  7  cm.) ,  intervention  for  the 
pelvic  complication  alone  was  required  in  less  than  9  per  cent.  (Below  2.76  inches — 7  cm. — 
the  percentage  of  intervention  for  the  pelvic  element  was,  of  course,  100  per  cent.)  In  the 
so-called  second  degree  of  contraction,  3.35  and  2.76  inches  (8.5  and  7  cm.),  the  percentage 
of  intervention  for  primipars  was  but  16,  although  much  higher  for  multiparas.  For  the 
so-called  first  degree  of  contraction,  3.74  and  3.35  inches  (9.5  and  8.5  cm.),  the  percentage 
of  intervention  was  but  2.7  per  cent.  In  222  cases  of  generally  contracted  pelvis  with  a 
true  conjugate  of  from  3.94  to  2.95  inches  (10  to  7.5  cm.)  intervention  for  the  pelvic  element 
alone  amounted  to  but  9  per  cent.  Below  the  measxirement  of  2.95  inches  (7.5  cm.)  (abso- 
lute contraction)  the  percentage  of  intervention  was,  of  course,  100.  In  the  second  degree 
of  contraction  alone  the  percentage  of  intervention  was  16  per  cent.,  and  in  the  first  degree, 
zero  In  other  words,  in  91  per  cent,  of  these  relatively  contracted  pelves  labor  was  of  the 
normal  type.  In  the  great  majority  of  cases  no  intervention  whatever  was  required.  In  a 
small  minority — 14  per  cent. — complications  arose  which  menaced  the  life  of  the  mother  or 
child  and  necessitated  the  use  of  the  forceps.  These  complications,  however,  had  no  connec- 
tion with  the  pelvic  deformity,  at  least  so  far  as  the  mother  was  concerned,  but  arose  from 
such  conditions  as  fever,  eclampsia,  placenta  praevia,  etc.  Indications  to  terminate  labor 
proceeding  from  the  state  of  the  fetus  may  or  may  not  have  been  due  to  the  pelvic  contrac- 
tion. Doubtless  there  was  a  greater  proportion  of  prolapse  of  the  funis  and  intrauterine 
asphyxia  than  in  labor  in  normal  pelves,  but  the  average  duration  of  labor  in  these  cases  was 
less  than  fifteen  hours,  which  is  within  normal  limits.  In  the  absence  of  good  control 
material  it  is  difficult  to  prove  that  the  size  of  the  pelvis  is  responsible  for  the  fetal  indica- 
tions for  forceps  in  KJronig's  cases.  The  children  were,  as  a  rule,  of  large  size  in  these  forceps 
cases.  Of  the  64  cases  in  which  it  became  advisable  to  interfere,  25  children  were  saved 
and  39  lost,  the  latter  number  including  cases  of  fetal  death  in  utero.  The  combined  fetal 
mortality  of  the  labors  of  "normal  type"  was  44,  or  about  10  per  cent.  This  figure,  how- 
ever, is  believed  to  represent  the  normal  fetal  death-rate  including  primary  and  secondary 


MATERNAL  DYSTOCIA   FROM   OBSTRUCTED   LABOR.  661 

In  order  to  appreciate  the  fact  that  every  case  of  labor  in  a  pelvis  relatively 
contracted  is  a  law  unto  itself,  and  must  be  managed  accordingly,  one  must 
study  the  phenomena  and  results  of  labors  in  which  there  has  been  no  inter- 
ference, namely,  in  which  expectancy  has  been  the  main  treatment.  This  has 
been  done  in  recent  years  at  the  obstetrical  clinics  of  Paris,  Vienna,  and 
especially  Leipzig,  where  the  work  of  Zweifel  and  Kronig  is  of  great  practical 
value. 

They  also  demonstrate  that  even  in  the  first  degree  of  relative  contraction 
spontaneous  labor  may  beimpossible.  The  outcome  of  a  particular  case  isdifficult 
to  foretell.  This  is  because  of  the  difficulty  of  proving  with  accuracy  the  com- 
parative size  of  the  fetal  head,  and  of  predicting  whether  sufficient  plasticity  of 
the  head  and  strong  uterine  contractions  will  be  present  in  a  given  case.  Both 
pelvimetry  and  cephalometry  have,  however,  in  the  past  few  years  made  great 
strides  toward  accuracy,  and  we  can  to-day  draw  very  definite  conclusions  by 
our  different  methods  of  examination  concerning  the  relative  size  of  a  given 
pelvis  and  fetal  head.     (See  Pelvimetry  and  Cephalometry,  pages  162  to  180.) 

Class  One.  First-degree  Contraction. — Simple  flat  pelvis  with  a  true  conjugate 
of  from  3.74  inches  (9.5  cm.)  to  3.35  inches  (8.5  cm.). 

Generally  contracted  pelves  with  a  true  conjugate  of  from  4  inches  (10  cm.)  to 
3.60  inches  (9  cm.). 

Spontaneous  labor  is  the  rule  in  this  class. 

Kronig*  in  several  hundred  flattened  pelves  of  this  class  found  that  the  percent- 
age of  intervention  was  but  2.7  per  cent. 

Should  there  be  an  absence  of  proper  uterine  contractions  or  should  defective 
head  moulding  or  a  large  head  be  present,  dystocia  may  ensue  and  failure  of 
the  head  to  engage  in  the  pelvic  inlet  occur. 

In  Pregnancy. — If  a  case  of  first -degree  contraction  is  seen  in  pregnancy 
before  term,  a  careful  estimate  of  the  available  space  at  the  pelvic  inlet  should 
be  made.  For  this  purpose,  I  prefer  internal  manual  pelvimetry  and  the  use 
of  the  Farabeuf  pelvimeter. 

The  fetal  biparietal  diameter  at  this  time  is  also  estimated  by  Ferret's  and 
Muller's  methods. 

Unless  some  special  contraindication  exists,  the  case  may  be  allowed  to  go 
to  full  term.     Prochownik's  diet  in  the  last  six  weeks  will  favor  eutocia. 

From  week  to  week  the  relation  between  the  size  of  the  head  and  the  inlet 
should  be  determined  by  Ferret's  method  of  cephalometry.  If  the  head 
deeply  engages  in  pregnancy,  of  course,  all  anxiety  ceases. 

The  borderland  cases  of  this  class,  with  short  conjugate,  will  render  it  dif- 
ficult to  predict  the  outcome  of  labor  at  term.  Should  cephalometr}^  determine 
a  disproportion  between  the  biparietal  and  true  conjugate  diameters,  then  the 
indication  of  premature  labor,  according  to  the  rules  laid  down  for  that  opera- 
tion in  contracted  pelves,  should  be  considered. 

In  Labor. — Since  spontaneous  labor  is  the  rule  in  these  pelves  of  the  first- 
degree  contraction,  labor  should  be  allowed  to  proceed  undisturbed  as  long  as 
possible,  and  interfered  with  only  for  a  positive  indication. 

Moulding  engagement  and  descent  usually  occur  after  a  reasonable  period 

mortality.  Kronig  and  others  who  incline  to  the  belief  that  labor  in  contracted  pelves  is 
physiological  up  to  a  certain  point,  admit  that  the  size  of  the  pelvis  contributes  to  the  death 
of  the  fetus  in  certain  cases.  But  no  control  statistics  of  labor  in  normal  pelves  are  pub- 
lished, and  as  the  average  duration  of  these  labors  is  not  beyond  the  normal,  it  is  possible 
that  this  concession  is  not  warranted  by  the  facts.  The  proportion  of  forceps  cases  is  not 
greater  than  in  many  miscellaneous  series. 
*  Loc.  cit. 


662  PATHOLOGICAL  LABOR. 

of  second-stage  pains,   provided   sufficient  plasticity  of  the  head   and  strong 
uterine  contractions  are  present. 

The  membranes  should  be  undisturbed,  and  in  delayed  cervical  dilatation, 
a  careful  bimanual  stretching  of  the  ring  of  the  os  I  have  found  a  valuable 
procedure. 

Our  aim  is  to  secure  engagement  of  the  head,  so  as  to  avoid  the  resort  to 
high  forceps  or  version,  if  possible.  To  this  end  the  Walcher  position  (Part  X), 
used  from  time  to  time,  will  increase  the  pelvic  inlet  conjugate  and  assist  in 
cephalic  engagement. 

The  forceps,  high,  medium,  or  low,  may  be  required  in  cases  of  prolonged 
second  stage,  and  under  the  same  conditions  as  in  delayed  second  stage  in 
general.  The  advice  to  perform  version  at  the  completion  of  the  first  stage, 
the  prophylactic  version  of  many  German  authorities,  in  all  cases  of  moderately 
contracted  pelves,  I  believe  is  rarely,  if  ever,  called  for,  and  by  reason  of  the 
rapid  extraction  thus  made  necessary,  is  almost  always  fatal  to  the  fetus. 

The  management  of  labor  with  relative  contraction  of  the  pelvis  may  be 
summed  up  as  follows :  Labor  should  be  allowed  to  proceed  and  the  character 
of  the  pains  and  the  moulding  of  the  head  noted.  In  vicious  presentations  and 
positions  it  may  be  necessary,  of  course,  to  perform  prophylactic  version.  If 
labor  progresses  satisfactorily,  the  case  may  be  left  to  nature  unless  an  indica- 
tion arise  to  terminate  it  rapidly.  If  it  becomes  evident  that  labor  is  making 
no  progress,  the  obstetrician  must  choose  between  forceps  and  version,  symphy- 
seotomy. Cesarean  section,  and  perforation. 

Class  Two.  Second-degree  Contraction. — Simple  fiat  pelvis  with  a  true  conjugate 
of  from  ;^.;^^inches  (8.5  cm.)  ^02.75  i'^ches{'j  cm.).  Generally  contracted  pelvis  with  a 
true  conjugate  of  from  3.50  inches  (8.g  cm.)  to  2.95  inches  (7.5  cm.). 

When  the  true  conjugate  is  over  2.76  inches  (7  cm.)  in  flat  and  2.95  inches 
(7.5  cm.)  in  generally  contracted  pelves,  the  possibility  of  the  spontaneous 
birth  of  a  full-term  child  of  average  size  must  be  remembered.  Although  it  is 
true  that  the  larger  sized  pelves  of  this  second-degree  contraction  may  and 
do  permit  of  spontaneous  labor,  still  one  must  remember  that  the  proportion 
of  spontaneous  births  sharply  diminishes  as  we  recede  from  the  limits  of  this 
degree  and  approach  those  of  absolute  pelvic  contraction.  (Less  than  2.76 
inches  (7  cm.)  in  flat  and  2.96  inches  (7.5  cm.)  in  generally  contracted  pelves.) 

Thus  Kronig  found  that  in  504  cases  of  labor  in  flattened  pelves  with  a  true 
conjugate  between  3.74  and  2.76  inches  (9.5  and  7  cm.),  relatively  contracted 
pelves,  intervention  for  the  pelvic  complication  alone  was  required  in  less  than 
9  per  cent.,  and  below  2.76  inches  (7  cm.)  the  percentage  of  intervention  for 
the  pelvic  element  was  100  per  cent. 

Kronig  also  found  that  in  222  cases  of  generally  contracted  pelves  with  a  true 
conjugate  of  3.94  to  2.95  inches  (10  to  7.5  cm.),  relatively  contracted  generally 
contracted  pelves,  intervention  for  the  pelvic  element  alone  amounted  to  but  9 
percent.    Below  2.95  inches  (7.5  cm.)  intervention  was  necessary  in  100  per  cent. 

On  the  other  hand,*  the  statistics  of  Ludwig  and  Savar  show  that 
intervention  was  necessary  with  a  true  conjugate  of 


2.76  inches 

(7  cm.)     in  100     per  ce 

2.96 

(7.5  cm.)  "     85        "       ' 

3.12 

(8  cm.)      "     75        "       ' 

3-35       " 

(8.5  cm.)   "     50.3    "       ' 

3-5°       " 

(9  cm.)      "     41-3    " 

3-75       " 

(9.5  cm.)   "     24-4    " 

*  '   Klin.    Bericht  liber  die   Geburten  beim  Engen  Becken,  Bericht  aus  der  II  Geburt. 
Gynecol.  Klinik  in  Wien,"  Wien,  1897,  120-353. 


MATERNAL  DYSTOCIA   FROM  OBSTRUCTED   LABOR.  663 

The  treatment  of  this  class  must  necessarily  vary  as  the  case  is  first  seen  in 
pregnancy  or  labor. 

In  Pregnancy. — The  same  general  principles  are  in  force  here  as  in  Class 
One.  Careful  watch  for  disproportion  between  the  head  and  pelvic  inlet  should 
be  kept  with  the  aid  of  Ferret's  and  Mtiller's  methods,  assisted  by  nitrous  oxide 
anesthesia,  if  necessary. 

With  the  lesser  degrees  of  contraction  of  this  class,  in  the  absence  of  marked 
disproportion,  pregnancy  may  be  permitted  to  proceed  to  full  term,  with  the 
assistance  in  the  last  six  weeks  of  Prochownik's  diet.  Should  it  appear  at 
any  time  from  the  estimate  of  the  size  of  the  fetal  head  that  serious  dystosia 
is  likely  to  ensue,  the  case  should  be  treated  as  in  the  more  marked  degrees  of 
this  class. 

In  the  greater  degrees  of  contraction  of  this  class  we  should  never  trust  to 
spontaneous  labor  at  term  except  in  the  case  of  twins  or  an  exceptionally 
small  fetus.  Thechoice  in  these  cases  lies  between  induction  of  labor  and  Caesarean 
section  at  or  near  term. 

Excellent  results  in  my  cases  have  been  obtained  by  inducing  labor  at  the 
thirty-sixth  week,  and  my  fetal  mortality  from  this  procedure  has  been  little 
if  any  greater  than  in  spontaneous  labor  at  term  in  normal  pelves. 

In  balancing  the  choice  between  induction  of  premature  labor  and  Caesarean 
section,  it  must  not  be  forgotten  that  although  a  small  premature  child  does 
readily  pass  through  a  contracted  pelvis  when  at  full  term  decided  dystocia 
would  occur,  still  the  premature  fetus  in  less  able  to  stand  punishment  either 
from  birth,  forceps,  or  other  pressure. 

For  example,  as  I  have  frequently  observed,  an  easy  forceps  or  breech 
extraction  at  the  thirty-fourth  week  is  likely  to  be  more  dangerous  to  the 
child  than  a  somewhat  more  difficult  operation  at  full  term. 

At  the  thirty-sixth  week  the  biparietal  diameter  is  Si  inches  (8.25  cm.),  and 
although  this  does  not  correspond  to  the  clinical  index  of  all  pelves  of  this 
class,  still  the  greater  plasticity  of  the  fetal  head  at  the  thirty-sixth  week  per- 
mits of  more  ready  moulding  than  at  term. 

The  fetal  mortality  so  progressively  increases  as  we  induce  labor  earlier 
than  the  thirty-sixth  week,  that  in  those  cases  of  this  class  bordering  upon 
absolute  pelvic  contraction  the  best  prognosis  for  the  child  is  obtained  by 
Caesarean  section,  and  this  should  be  the  operation  of  choice  in  such  instances. 

In  Labor. — In  the  lesser  degrees  of  contraction  of  this  class  the  same  gen- 
eral principles  obtain  as  in  Class  One. 

In  the  cases  bordering  upon  absolute  contraction,  interference  will  almost 
surely  be  required.  Should  a  decided  disproportion  between  head  and  inlet 
exist,  or  if  after  several  hours  of  second-stage  contractions  the  head  has  shown 
no  tendency  to  engage  and  descend  some,  the  likelihood  of  spontaneous  deliv- 
ery or  of  delivery  by  forceps  or  version  is  quite  out  of  the  question.  The 
choice  will  now  rest  between  Caesarean  section,  symphyseotomy, and  perforation. 
Version,  in  these  cases,  only  adds  to  the  dangers  of  the  situation.  It  almost 
surely  destroys  the  child,  and  the  extraction  gives  a  bad  prognosis  for  the 
mother. 

The  forceps  should  only  be  used  tentatively,  for  a  short  time,  assisted  by 
the  Walcher  posture,  and  never  with  great  force  or  prolonged  traction. 

As  in  absolute  contraction,  Caesarean  section  should  here  be  the  operation 
of  choice,  but  with  this  exception,  namely,  only  when  the  fetus  is  alive.  This 
class  of  deformity  will  usually  permit  of  craniotomy  when  the  child  is  dead, 
and  here,  as  in  other  forms  of  pelvic  contraction,  no  sentimental  or  esthetic 


664  PATHOLOGICAL  LABOR. 

reasons  should  ever  prevent  us  from  mutilating  a  dead  fetus,  when  thereby  we 
lessen  the  dangers  to  the  mother. 

My  experience  with  and  observation  of  many  cases  of  symphyseotomy  for 
pelvic  contraction,  does  not  permit  me  to  recommend  the  operation  as  a 
competitor  with  Caesarean  section.  The  physician  may  be  met  with  the  refusal 
of  the  mother  and  her  family  to  accept  Caesarean  section. 

Again,  in  sparsely-settled  country  districts,  where  assistance  is  not  at  hand, 
and  in  tenement-house  practice,  where  a  patient  refuses  to  be  removed  to  the 
hospital,  the  practitioner  is  occasionally  compelled  to  sacrifice  a  living  child. 

In  city  practice,  however,  the  physician  can  always  refuse  to  perform 
embryotomy  on  a  living  fetus,  as  there  are  competent  physicians  at  hand  to 
whom  the  case  can  be  transferred. 

Again,  if  the  patient  when  first  seen  already  shows  symptoms  of  infection 
by  reason  of  a  midwife's  attendance,  or  repeated  unsuccessful  attempts  at 
delivery,  Caesarean  section  should  not  be  attempted  by  reason  of  the  high 
maternal  mortality  in  such  cases. 

In  this  last  class,  however,  should  the  demands  of  the  Catholic  Church  or  a 
great  degree  of  pelvic  deformity  demand  Cesarean  section,  a  complete  or  in- 
complete hysterectomy  should  follow  the  operation. 

Forceps  and  Version  in  Contracted  Pelves. — To  expectancy  in  the  management 
of  pelvic  contraction,  we  may  add,  according  to  the  indications,  the  forceps 
and  version,  the  latter  followed  by  immediate  manual  extraction. 

Both  the  measures  have  often  been  sufficient  to  overcome  considerable 
degrees  of  pelvic  dystocia.  The  forceps  is  indicated  in  those  cases  in  which  the 
head  is  engaged  or  can  be  made  to  partially  engage  by  suprapubic  pressure, 
and  in  which  our  previous  examination  assures  us  there  is  no  decided  dispropor- 
tion between  the  head  and  pelvic  inlet.  As  a  general  rule,  a  tentative  attempt 
to  assist  delivery  by  the  careful  use  of  the  forceps  should  be  made  in  all  cases, 
before  any  more  serious  operation  is  undertaken.  Excessive  and  prolonged 
traction  with  the  forceps  must  not  be  made  use  of,  as  destruction  of  the  fetus 
and  possibly  fatal  results  for  the  mother  are  quite  likely  to  result. 

At  the  Bellevue  and  Manhattan  Maternity  services  undelivered  women  are 
frequently  received,  seriously  torn  and  infected  following  prolonged  and  brutal 
attempts  at  forceps  delivery. 

It  is  a  good  plan,  before  doing  any  operation,  to  attempt  to  assist  delivery 
by  the  means  suggested  for  prolonged  unobstructed  labor  (page  572)  and  by 
the  Walcher  position.  Too  much  must  not,  however,  be  expected  by  this  last 
manoeuvre. 

The  forceps  possesses  the  advantages  of  permitting  a  great  degree  of  trac- 
tion and  a  gradual  extraction  of  the  head.  Its  disadvantages  are  (i)  that 
pressure  over  one  diameter  increases  the  length  of  the  opposite;  (2)  the  in- 
strument occupies  a  certain  space  in  the  already  small  pelvis.  Version  has  for 
its  advantages  :  (i)  the  diameter.s  of  the  head  are  not  increased  by  a  foreign 
body;  the  wedge-shape  of  the  after-coming  head  adapts  better  to  the  inlet  than 
the  shape  of  the  fore-coming  head.  Its  disadvantages  are  :  (i)  no  great  force 
can  be  exerted  upon  the  fetal  body  or  neck;  (2)  rapid  extraction,  ten  minutes 
at  the  longest,  is  necessary  to  secure  a  live  child;  (3)  the  complications  of 
extension  of  the  head  and  arms  are  always  liable  to  occur,  seriously  affecting 
the  prognosis. 

Face,  Brow,  and  Breech  Presentations  in  Contracted  Pelves. — Face  and  brow 
presentations  always  suggest  pelvic  deformity  of  some  variety  (p.  509),  but  not 
necessarily  to  a  serious  degree.     In  moderate  degrees  of  pelvic  contraction,  the 


MATERNAL  DYSTOCIA   FROM   GENERAL  CONDITIONS.  665 

treatment  of  face  and  brow  presentations  which  I  have  suggested  elsewhere 
(p.  517)  is  to  be  relied  upon.  In  more  marked  deformity  too  much  cannot  be 
expected  of  the  face  or  of  the  converted  brow  in  the  way  of  moulding  and 
engagement,  and  radical  measures  for  the  safety  of  mother  and  fetus  should  be 
considered  at  the  outset. 

Breech  presentation  is  rather  unfavorable  for  the  fetus,  because  of  the  delay 
in  the  moulding  and  engagement  of  the  breech,  in  the  likelihood  of  prolapse  of 
the  cord,  and  fatal  asphyxia  in  the  extraction  of  the  aftercoming  head. 
For  the  mother,  unless  the  deformity  is  severe,  a  breech  presentation 
is  rather  favorable,  because  of  the  less  dangerous  pressure  caused 
by  the  buttocks  of  the  fetus,  and  since  extraction  can  usually  be  safely  accom- 
plished should  occasion  arise. 

The  prophylactic  bringing  down  of  a  foot,  soon  after  the  rupture  of  the 
membranes,  is  a  good  plan  in  moderate  relative  contractions,  to  afford  us  a 
handle  for  subsequent  extraction,  should  the  latter  become  necessary. 


MATERNAL  DYSTOCIA  FROM  GENERAL  MATERNAL   CONDI- 
TIONS. 

XXII.    LABOR  IN  ELDERLY  PRIMIPARAE. 

Definition. — An  elderly  primipara  is  one  who  is  thirty  years  of  age  and  up- 
ward. Some  authorities  would  even  make  twenty-eight  years  the  boundary- 
line,  while  others  regard  thirty-two  as  the  proper  limit  of  youth. 

Etiology. — The  causes  of  late  primiparity  by  no  means  coincide  with  late 
marriage.  They  are  to  be  sought  in  part  in  uterine  malpositions,  metritis,  cer- 
vical catarrh,  tumors,  congenital  malformations,  sexual  frigidity,  also  in  inabil- 
ity of  the  husband  to  procreate.  The  condition  of  the  woman  of  which  she  is 
most  conscious  and  which  influences  her  against  matrimony  is  contracted  pelvis. 
When,  as  often  happens,  this  is  due  to  rickets  or  some  skeletal  deformity,  she  is 
not  sought  in  marriage  during  the  age  at  which  men  pay  attention  to  externals 
in  selecting  brides.  Sooner  or  later,  too,  these  women  learn  something  about  con- 
tracted pelves,  and  therefore  fear  conception.  The  causes  of  the  prolongation  of 
these  labors  are  described  under  "anatomical  rigidity  of  the  cervix"  and 
"rigidity  of  the  vagina,  vulva,  and  perineum." 

Symptoms. — After  an  elderly  primipara  conceives,  her  pregnancy  and  labor 
may  exhibit  certain  peculiarities.  Twin  pregnancy  appears  from  statistics  to  be 
common  among  these  women.  There  is  a  higher  proportion  of  malaise  and  gas- 
tric disturbance  in  the  elderly.  Kleinwachter  thinks  that  the  tendency  to  pla- 
cental hemorrhages  is  less  marked.  The  same  author  found  a  high  percentage  of 
renal  mischief  in  those  above  thirty-five,  while  there  is  testimony  from  numerous 
sources  that  eclampsia  is  more  frequent.  In  regard  to  the  duration  of  labor, 
Courtade  obtained  an  average  of  twenty-two  hours  and  twenty-seven  minutes. 
Nearly  nineteen  hours  of  this  time  was  consumed  in  dilatation.  As  intervention 
was  practised  in  a  number  of  cases,  the  results,  after  eliminating  the  latter, 
showed  about  sixteen  and  a  half  hours  for  the  entire  labor,  and  fourteen  and  three- 
quarters  hours  for  dilatation  alone.  After  the  further  elimination  of  some  pre- 
mature cases,  Courtade  decides  that  the  average  duration  of  labor  in  the  elderly 
is  sixteen  hours ;  his  cases  begin  at  the  age  of  twenty-eight.  Ahlfeld,  with  whom 
the  age  of  elderly  primiparity  does  not  begin  till  thirty-two,  finds  the  average 
duration  of  labor  to  be  twenty-seven  hours ;  while  Kleinwachter  makes  the  figure 


666  PATHOLOGICAL  LABOR. 

eighteen  hours.  In  30  spontaneous  labors  after  the  thirtieth  year  I  found  the 
average  duration  of  labor  to  be  fifteen  hours  and  forty-nine  minutes.  There  are 
no  known  modifications  of  the  third  stage  of  these  labors  with  the  exceptions 
according  to  some,  of  a  tendency  to  adhesion  and  retention  of  the  placenta.  As 
might  be  expected,  lacerations  of  the  birth  tract  are  more  common  in  the  elderly, 
amounting  to  30  per  cent.  Statistics  readily  show  that  the  proportion  of  cases 
of  operative  interference  increases  with  age:  thus,  from  thirty  to  thirty-five,  13.6 
per  cent.;  over  thirty-five,  14.58  per  cent.;  jointly,  14.2  per  cent.  In  regard  to 
children,  the  tendency  of  the  elderly  primipara  is  to  produce  more  boys  than 
girls.  The  average  weight  of  the  newly  bom  is,  according  to  Mangiagalli  and 
Kleinwachter,  less  than  that  of  children  of  young  primiparae.  The  tendency  to 
vicious  presentation  is  greater  with  the  advance  of  age  of  the  primipara;  I  found 
6  per  cent,  in  47  cases.  Finally,  the  child  mortality  is  said  to  be  much  higher. 
The  figures  range  from  14.24  per  cent.  (Courtade)  to  44.8  per  cent.  (Cohnstein). 
In  my  47  cases  the  maternal  and  fetal  mortality  was  nil.  I  append  the  private 
statistics  of  Courgenon,  obtained  from  a  study  of  all  labors  in  women  over  thirty 
at  the  Clinique  Tamier,  1898-1899,  as  well  as  my  own  material. 

In  the  Clinique  Tamier  of  Paris,  of  a  total  ntiniber  of  iii  cases,  81  ended  spontaneously 
(73  per  cent.)  and  the  remainder  were  terminated  with  forceps.  Post-partum  hemorrhage 
occurred  in  8  per  cent.  The  average  duration  of  labor  was  seventeen  hours  thirty  minutes. 
There  were  about  5  per  cent,  of  vicious  presentations  and  8  per  cent,  of  pelvic  deformity. 
Uterine  inertia  was  present  in  19  per  cent.  About  6  per  cent,  of  women  had  albuminuria, 
but  none  developed  eclampsia.  There  was  one  case  of  placenta  prsevia.  The  maternal 
mortality  was  less  than  2  per  cent.,  the  fetal  less  than  4  per  cent.  In  2200  cases  of  labor  I 
found  the  total  number  of  elderly  primiparas  to  be  47,  of  which  30  ended  spontaneously 
(63.8  per  cent.);  the  remainder  terminated  with  forceps.  Four  patients  (8.5  per  cent.) 
had  post-partum  hemorrhage.  The  average  duration  of  spontaneous  labor  was  fifteen 
hours  forty-nine  minutes.  There  were  about  6  per  cent,  of  vicious  presentations  and  25  per 
cent,  of  pelvic  deformities.  Uterine  inertia  was  present  in  but  4  per  cent.;  if,  however,  we 
reckon  the  cases  of  post-partum  hemorrhage  under  inertia,  the  percentage  is  nearly  13. 
There  were  no  cases  of  placenta  prcevia.     The  maternal  and  the  fetal  mortality  was  each  o. 

Conclusions. — The  statistics  of  Courtade,  of  Courgenon  of  the  Tamier  Clinic, 
and  my  own  material  appear  to  show  that  labor  in  elderly  primiparae  is  but 
slightly  longer  on  the  average  than  in  primiparae  in  general.  Normal  labor  with 
first-bom  children  is  computed  to  last  from  twelve  to  fifteen  hours  (Tamier).  In 
the  author's  material  the  average  duration  was  fifteen  hours  twenty-nine  minutes — 
only  some  twenty  minutes  less  than  in  the  elderly  alone.  Hence  the  duration 
obtained  by  Ahlfeld  and  others. (twenty-seven  hours,  twenty-five  hours,  etc.)  can- 
not be  attributed  to  mere  age.  Again,  the  low  maternal  and  fetal  mortality  of 
the  Tamier  Clinic  and  my  cases  show  that  the  heavy  mortality  of  certain 
statisticians  (14.2  per  cent.,  44.8  per  cent.)  should  be  attributed  neither  to  the  age 
of  the  parturients  nor  to  the  instrumental  intervention.  The  most,  then,  that 
can  be  said  of  the  influence  of  age  on  primiparity  is  that  it  slightly  prolongs  the 
first  stage  of  labor  and  somewhat  increases  the  frequency  of  indications  for  the 
use  of  the  forceps.  The  same  conclusion  is  also  reached  by  Courgenon.  This  is, 
of  course,  opposed  to  the  tradition  which  prevails  in  both  medical  and  lay  circles 
and  also  appears  to  discredit  the  existence  of  what  is  known  as  "anatomical 
rigidity  of  the  cervix,"  which  is  believed  to  be  almost  uniformly  present  in  elderly 
primiparae  (page  606).  Tamier  and  Budin  hold  that  the  condition  of  absolute 
undilatable  cervix,  which  sometimes  gives  way  to  circular  rupture  rather  than 
yielding  naturally,  is  excessively  rare,  and  not  to  be  confounded  with  the  rigidity 
which  is  almost  universally  present  in  the  primipara,  and  even  in  the  multipara 
in  premature  labors.  The  coincidence  of  extreme  anatomical  rigidity  in  a  few 
labors  in  elderly  primipars  might  well  beget  the  impression  that  such  an  associa- 
tion was  inevitable,  but,  as  has  been  shown,  there  is  no  sound  basis  for  such  an 


MATERNAL  DYSTOCIA   FROM  GENERAL  CONDITIONS.         667 

opinion.  What  were  the  real  causes  of  the  extreme  duration  of  labor  and  the 
high  maternal  and  fetal  mortality  registered  by  competent  observers  in  connection 
with  primiparity  after  thirty  years  of  age  ?  Possibly  the  mothers  were  influenced 
unfavorably  by  the  belief  in  the  fatal  issue  of  such  labors.  The  problem  is  an 
important  one,  for  in  an  era  of  late  marriage  and  low  birth-rate  many  women 
avoid  maternity  on  the  ground  that  they  are  too  old  for  bearing  children  without 
great  hazard  to  themselves.  It  is  known  that  for  some  reason  late  breeders 
possess  a  higher  proportion  of  pelvic  deformity  than  younger  women.  I  found 
25  percent,  of  pelvic  deformity  in  my  47  cases  of  elderly  primiparity. 


XXIII.  INTESTINAL  HERNIA.     VAGINAL  HERNIA. 

The  ordinary  forms  of*  hernia — inguinal,  crural,  and  umbilical — can  hardly 
be  ranked  among  causes  of  maternal  dystocia.  On  the  other  hand,  there  is  a 
special  type  of  hernia — namely,  the  vaginal — which  should  be  enumerated  among 
such  causes.  Here  the  usual  course  of  the  prolapsed  intestine  is  to  occupy 
Douglas's  pouch,  although  in  rare  instances  it  may  descend  in  front  of  the  uterus. 
The  gut  may  remain  in  Douglas's  cul-de-sac  or  descend  between  the  vagina  and 
the  rectum.  In  the  latter  case  it  may  appear  at  the  perineum  or  in  one  of  the 
labia  majora.  For  vaginal  hernia  to  occur,  some  anomaly  of  form  of  Douglas's 
cul-de-sac  should  furnish  a  predisposition.  Such  anomalies  may  be  produced  by 
a  prolapse  or  retroversion  of  the  uterus  which  tends  to  stretch  the  retrouterine 
ligaments.  The  accident,  essentially  rare,  occurs  much  more  frequently  in  the 
multiparous.  Vaginal  hernia  may  consist  of  both  intestine  and  omentum.  In 
the  rare  anterior  form  the  hernia  may  comprise  part  of  the  bladder.  These 
hernias  seldom  cause  symptoms  during  gestation.  In  a  few  rare  instances  the 
size  of  the  mass  has  been  known  to  cause  obstructive  phenomena  affecting  the 
rectum  and  bladder.  In  a  few  cases  rupture  of  the  sac  has  been  known  to  occur 
before  delivery.  From  the  standpoint  of  dystocia,  vaginal  hernia,  if  large,  offers 
some  hindrance  to  the  descent  of  the  head;  but  the  danger  concerns  the  mother 
principally,  since  the  prolonged  compression  of  the  hernia  may  terminate  in 
strangulation  and  necrosis  of  the  gut.  Diagnosis  should  be  easy.  If  in  the 
course  of  digital  examination  the  finger  encounters  a  bulging,  elastic  mass 
in  the  posterior  cul-de-sac,  and  if  this  tumor  is  reducible,  there  can  be  little 
doubt  as  to  its  nature.  Nevertheless,  vaginal  hernia  has  been  mistaken  for 
a  great  number  of  conditions,  including  the  bag  of  waters,  rectocele,  cyst  of 
the  vagina  or  ovary,  etc.  If  the  hernia  has  made  its  way  to  the  labium  majus  and 
the  fact  of  intestinal  protrusion  is  recognized,  the  physician  will  naturally  be- 
lieve it  to  be  an  inguinal  hernia.  In  such  a  case  Stoltz's  test  should  be 
applied  as  follows:  The  hernia  is  reduced,  the  inguinal  ring  closed  by  the  thumb, 
and  the  woman  instructed  to  cough;  if  now  the  tumor  reappears  in  the  labium, 
an  inguinal  hernia  may  be  excluded.  The  hernia  is  now  reduced  for  the  second 
time  and  a  finger  in  the  vagina  compresses  the  latter  against  the  ischium  on 
the  side  of  the  hernia.  If  the  patient  coughs  now,  the  hernia  does  not  reap- 
pear. Treatment:  If  the  diagnosis  of  vaginal  hernia  is  made  early  enough  in  the 
course  of  the  labor,  the  indication  is  to  reduce  the  hernia  and  hold  it  back  until 
the  descent  of  the  head  into  the  vagina  prevents  any  further  probability  of  pro- 
lapse during  labor.  To  reduce  the  hernia  it  may  be  necessary  to  apply  the  taxis 
under  an  anesthetic,  although  the  knee-chest  position  may  answer  in  some  cases. 
Conjoined  manipulation  (abdomino-vaginal  and  vagino-rectal)  may  in  certain 
cases  serve  for  the  reposition.  In  irreducible  hernia  during  labor  the  indica- 
tion is  to  terminate  the  latter  with  all  haste  after  dilatation  has  occurred. 


668  PATHOLOGICAL   LABOR. 


XXIV.  CARDIAC  AND  PULMONARY  DISEASE. 

Asystole  in  Labor. — The  bearing  of  organic  heart  disease  upon  marriage, 
pregnancy,  and  the  interruption  of  gestation  has  already  been  considered 
(page  326).  If  a  patient  in  whom  the  disease  has  passed  the  period  of  com- 
pensation should  become  pregnant  and  go  on  to  term,  death  is  pretty  cer- 
tain to  happen  during  delivery.  Neumann  *  publishes  a  case  of  this  sort  and 
cites  a  number  of  similar  instances.  Under  these  circumstances,  however,  it 
has  been  possible  to  save  the  child's  life  by  rapid  forceps  extraction.  (See  Coffin 
Birth,  page  669.)  If  the  woman  is  not  dead  but  nearly  moribund  when  the 
physician  reaches  the  lying-in  chamber,  it  is  still  possible  to  rescue  her,  as  shown 
by  a  case  cited  by  Neumann.  The  patient,  six  months  pregnant,  was  asystolic, 
presenting  anasarca,  ascites,  and  orthopnea.  She  was  held  in  a  nearly  upright 
position  by  several  attendants  for  some  hours,  or  until  the  cervix  could  be  dilated 
and  the  child  perforated  and  extracted.  She  recovered  from  the  asystole.  In 
labor  with  organic  heart  disease  properly  compensated,  the  indications  do  not 
vary  from  those  which  obtain  in  delivery  under  normal  conditions.  It  has  been 
claimed  that  the  rapid  fall  in  the  intra-abdominal  pressure  which  follows  the 
emptying  of  the  uterus  in  these  cases  may  lead  to  death  post-partum.  To  lessen 
the  danger  a  sand-bag  can  be  placed  upon  the  abdomen  after  delivery. 

Pulmonary  Disease. — Acute  obstruction  of  the  larynx  from  any  cause  may 
bring  on  labor,  and  under  these  circumstances  the  fetus  is  likely  to  perish  from 
asphyxia  in  utero.  Tracheotomy  is  indicated  in  the  interest  of  both  mother 
and  fetus.  If  after  tracheotomy  the  mother  is  moribund,  Caesarean  section 
may  save  the  child.  If  pneumonia  coexists  with  labor,  the  cardiac  insufficiency 
which  accompanies  this  disease  may  lead  to  acute  pulmonary  oedema  and  death. 
If  labor  is  impending  during  pneumonia,  efforts  should  be  directed  to  securing 
delay.     After  labor  is  under  way  it  should  be  hastened  with  all  due  speed. 


XXV.  CEREBRAL  AND  SPINAL  DISEASE. 

The  severe  forms  of  neuroses,  such  as  epilepsy,  hysteria  major,  and  the  grave 
form  of  chorea  gravidarum,  appear  to  exert  but  little  influence  on  the  labor. 
Meningitis  has  sometimes  occurred  in  pregnancy  either  with  or  without  erysipelas. 
When  labor  begins,  convulsions  develop.  Cases  of  labor  complicated  with  chronic 
spinal  diseases  are  on  record.  One  case  is  recorded  in  which  there  was  a  chronic 
myelitis  of  the  whole  cord  with  paraplegia  and  anesthesia  extending  as  high  as 
the  umbilicus.  The  mother  suffered  no  pain.  In  tabes  dorsalis  the  course  of 
labor  is  normal  in  the  great  majority  of  cases. 

Delirium  or  Insanity  of  Labor. — In  very  sensitive  patients  the  natural 
suffering  and  restlessness  incident  to  labor  may  pass  into  a  state  of  transient 
fury,  the  explosions  occurring  during  the  pains.  These  women  tear  their  hair, 
beat  the  wall,  and  indulge  in  furious  cursing.  This  acute  psychosis  is  especially 
noticeable  in  unmarried  women,  as  I  have  observed  numerous  cases  at  the 
Emergency  and  New  York  Maternity  Hospitals  among  this  class  of  patients. 
After  delivery  the  patient  has  no  recollection  of  this  state  of  mind.  Technically 
this  condition  is  an  acute  delirium  and  not  true  insanity.  The  treatment  is 
based  upon  general  principles. 

*  ■'  Centralbl.  f.  Gynak.,"  March  10,  1900. 


MATERNAL  DYSTOCIA   FROM  GENERAL  CONDITIONS.         669 


XXVI.  DIGESTIVE    DISTURBANCES. 

Pernicious  Vomiting. — Under  certain  circumstances  labor  may  be  much 
disturbed  by  pernicious  vomiting.  The  causes  comprise  actual  organic  disease 
of  the  stomach  and  functional  disturbance  from  errors  in  diet.  The  determining 
cause  of  a  paroxysm  of  vomiting  is  a  severe  labor  pain.  The  coincidence  of 
labor  and  vomiting  is  not  unusual  in  anemic  primiparas.  Mental  emotion  is  also 
a  cause.  As  this  vomiting  may  presage  the  development  of  eclampsia  or  some 
other  affection,  it  is  best  to  terminate  labor  at  once.  Hematemesis  may  occur 
during  labor  when  gastric  cancer  or  ulcer  is  present,  but  it  does  not  constitute 
an  indication  for  hastening  delivery.  Rupture  of  the  spleen  sometimes  occurs 
during  labor  and  always  ends  fatally. 


XXVII.  SUDDEN  DEATH  DURING  LABOR. 

Sudden  death  may  occur  during  parturition  from  a  great  variety  of  causes. 
Predisposing  causes  may  exist  before  labor,  the  latter  acting  as  a  determining 
cause;  or  the  death  may  be  the  termination  of  a  condition  produced  by  pregnancy 
itself,  (i)  The  predisposing  causes  independent  of  pregnancy :  (a)  Circiilatory 
— valvular  heart  disease,  rupture  of  a  diseased  aorta,  hydropericardium,  fatty 
heart;  (b)  respiratory — suffocation  during  labor  from  presence  of  a  goiter,  or 
from  hydrothorax;  (c)  digestive,  etc. — rupture  of  spleen;  (d)  cerebrospinal — 
cerebral  apoplexy.  (2)  Predisposing  causes  as  a  consequence  of  pregnancy: 
(a)  Eclampsia;  (b)  hemorrhage,  as  from  placenta  praevia,  too  early  detach- 
ment of  a  normally  seated  placenta,  rupture  of  the  uterus,  or  of  varicose  veins  in 
the  broad  ligament;  (c)  entrance  of  air  into  veins:  this  accident  occurs  in  pla- 
centa praevia,  cancer,  rupture  of  the  uterus,  and  in  manual  and  instrumental 
intervention.  (3)  Unknown  causes  of  death.  Death  has  occurred  suddenly 
from  the  mere  introduction  of  the  hand  into  the  vagina  for  the  purpose  of  per- 
forming version.  (4)  Shock.  (See  Part  VH.)  (See  Sudden  Death  in  the 
Puerperium,  Part  VIL) 


XXVIII.  POST-MORTEM  DELIVERY— COFFIN   BIRTH. 

Post-mortem  parturition  acquires  its  obstetrical  and  medico-legal  importance 
from  the  possibility  of  physicians  and  midwives — the  latter  particularly — being 
made  defendants  in  suits  for  malpractice  on  the  ground  of  the  delivery  of  the 
child  after  the  death  of  the  mother,  and  on  the  contention  that  this  accident  was 
preventable  and  due  to  lack  of  skill  or  to  ignorance  on  the  part  of  the  practi- 
tioner. The  case  reported  by  Moritz  *  is  the  best  illustration  to  be  found  of  this 
charge.  Three  theories,  according  to  Aveling,t  have  been  advanced  in  explana- 
tion of  the  phenomenon.  The  first  is  that  it  is  caused  by  the  contraction  of  the 
uterine  walls  in  rigor  mortis.  This  seems  hardly  worth  consideration,  for  the 
contractions  are  not  sufficiently  powerful  to  overcome  the  natural  obstacles 
to  the  passage  of  the  child,  with  the  superadded  narrowing  and  rigidity  of  the 
parturient  canal  from  the  same  cause.  The  second  theory  is  the  pressure  of  the 
putrefactive  gases  in  the  abdominal  cavity,  acting  on  the  point  of  least  resistance, 
expelling  the  fetus  and  pushing  the  uterus  before  it  until  it  lies  outside  the 

♦Moritz:  "  Vierteljahresschrift  f.  gericht.  Med.,"  p.  93,  Bd.  v,  1893;  also  Bleisch: 
"  Vierteljahresschrift  f.  gericht.  Med.,"  1892,  Bd.  iii,  p.  38. 


670  PATHOLOGICAL  LABOR. 

genitals  distended  with  foul-smelling  gaseous  products.*  There  can  be  no  doubt 
that  this  explanation  is  the  true  one  in  a  majority  of  instances,  but  there  still 
remains  a  class  of  cases  which  it  will  not  explain,  since  the  birth  took  place  too 
early  for  decomposition  to  have  advanced  so  far  as  to  produce  sufficient  pressure 
of  gas.  To  cover  this  ground  a  third  cause  has  been  proposed  in  the  conservation 
of  power  in  the  uterine  muscle  for  some  time  after  death  (two  hours  is  the  limit 
generally  placed).  This  contractile  irritability  preserved  after  death  has  been 
noted  by  various  writers.  Fodere  f  says  that  "the  uterus  may  expel  the  fetus 
after  death,  its  organic  action  being  conserved  after  dissolution  has  taken  place." 
BaudelocqueJ  found  the  uterus  contracted  after  the  lapse  of  a  few  hours  in  a 
woman  whom  he  had  delivered  immediately  after  death.  Arbeiter  §  found  a 
like  condition  of  affairs,  delivery  of  the  child  having  been  accomplished  by 
version  and  extraction  three-quarters  of  an  hour  after  death.  During  the 
operation  the  uterus  was  flaccid,  but  it  contracted  later  into  a  hard  ball.  Leroux|| 
cites  a  case  of  the  same  character,  and  others  are  on  record.  The  uterus  is  often 
said  to  be  the  last  portion  of  the  body  to  lose  its  power  of  contraction  and  the 
last  also  to  undergo  decomposition.  It  is  possible,  then,  to  believe  that  when 
birth  occurs  within  a  few  hours  after  the  mother's  death,  the  force  retained  in  the 
voluntary  muscles  of  the  walls  of  the  uterus  is  sufficient  to  complete  the  labor. 

Dr.  W.  W.  Rangeley,  of  Christainsburg,  Virginia,  in  a  personal  communication,  has 
kindly  furnished  me  with  the  following  case  of  coffin  birth:  Upon  May  7,  1901,  Mrs.  J.  Vaden 
died  suddenly,  and  after  the  usual  interval  was  buried,  she  being  at  the  time  of  her  death 
ten  months  pregnant.  All  the  parties  present  at  the  time  the  body  was  placed  in  the  coffin 
testified  that  at  that  time  there  was  no  evidence  of  birth.  Subsequently  the  husband  was 
suspected  of  having  poisoned  his  wife,  so  on  May  18,  1901,  the  coffin  was  opened  in  the  pres- 
ence of  a  coroner's  jury,  and  the  body  examined  by  Drs.  Rangeley  and  M.  B.  K.  Linkous. 
The  abdomen  was  partly  distended  with  gas  so  as  to  resemble  pregnancy,  and  it  was  the 
first  impression  that  the  fetus  had  not  been  bom.  Incision  of  the  abdomen  caused  it  to 
collapse,  and  then  search  was  made  for  the  child,  which,  with  cord  and  placenta  attached, 
was  found  well  down  under  the  thighs.  The  child  weighed  nine  and  a  half  pounds  and  was 
dead.  The  uterus  was,  unfortunately,  not  examined.  The  body  was  in  a  state  of  decomposi- 
tion, but  the  fetal  cadaver  was  well  preserved.  The  cord  was  strong  enough  to  sustain  the 
weight  of  the  placenta  when  suspended.  The  opinion  of  the_ physicians  present  was  that  the 
intra-abdominal  gas  pressure  expelled  the  fetus  after  the  effects  of  rigor  mortis  had  subsided. 

Can  the  Fetus  Live  After  the  Death  of  the  Mother? — While  we  may  be  per- 
mitted a  doubt  in  such  a  case  as  that  of  Reiss,**  in  which,  according  to  that 
author,  a  day  passed  before  a  living  child  was  bom,  the  answerto  the  question  must 
be  in  the  affirmative  when  the  interval  is  only  an  hour  or  less.  In  the  discussion 
of  Aveling's  paper.  Dr.  Madge  ff  stated  that  he  had  observed  fetal  movements 
after  death  in  several  cases  and  wished  to  extract  the  child  by  Cassarean  section 
but  was  not  permitted.  Brunton  %%  after  a  quarter  of  an  hour  extracted  a  living 
child  from  the  mother's  corpse.  BufEon  and  Shierig  have  taken  living  animals 
from  the  bodies  of  female  beasts  hours  after  death.  The  author  has  done  the 
same  in  the  case  of  a  fox.§§ 

*  See  cases  65  to  67,  author's  article  in  Witthaus  and  Becker:  "  Medical  Jurispru- 
dence," vol.  II,  pp.  370—376. 

t  "M6d.  L6g.,"  vol.  II,  p.  II.  X  "Diet,  des  Sciences  M6d.,"  xxx,  p.  388. 

§  "Monats.  f.  Geburtsh.,"  April,  1862.  |I  "Traits  des  Pertes  de  Sang." 

**  G.  A.  Reiss:  "Gentleman's  Magazine,"  vol.  xxix,  p.  390. 
tt  "Trans.  Obstet.  Soc.  London,"  xiv,  p.  240.  %%  Ibid.,  xiii,  p.  88. 

§§  For  instances  in  which  living  children  have  been  extracted  from  fifteen  to  thirty-two 
minutes  after  the  mother's  death,  consult  Breslaw:  "Monats.  f.  Geburts.,"  B.  20,  p.  62; 
Pringler:  "Monats.  f.  Geburts.,"  B.  34,  S.  244  u.  251;  Botherston:  "Edinburgh  Med.  Jour.," 
April,  1868,  p.  930;  Welponer:  "Wiener  med.  Presse,"  No.  i,  1897;  Buckel:  "Trans.  Lon- 
don Obstet.  Soc,"  XIX,  p.  179;  Edgar:  Witthaus  and  Becker,  "Medical  Jurisprudence,"  vol. 
II,  pp.  369-379  (William  Wood  &  Co.,  New  York,  1894). 


MATERNAL  DYSTOCIA   FROM  GENERAL  CONDITIONS.        671 


XXIX.  THE  METRORRHAGIA  OF  LABOR;  PARTUM  OR  INTRA-PARTUM 

HEMORRHAGE. 

For  convenience'  sake,  I  am  accustomed  to  describe  intra-partum  hemor- 
rhages as  those  of — (i)  the  first  and  second  stages;  and  (2)  of  the  third  stage, 
(i)  Intra-partum  hemorrhage  of  the  first  and  second  stages:  This  is  due  principally 
to  (a)  premature  separation  of  a  normally  or  abnormally  situated  placenta;  (b) 
ruptures  of  the  uterus  or  cervix;  and  (c)  fibroid  tumors,  malignant  disease  of  the 
genital  tract,  or  rupture  of  varicose  veins.  (2)  Intra-partum  hemorrhage  of  the 
third  stage;  Here,  first  and  foremost  stands  (a)  uterine  inertia  as  the  most  impor- 
tant etiological  factor;  uterine  inertia  occurring  with  a  partial  or  complete  separa- 
tion of  the  placenta.  Next  in  importance  come  (6)  lacerations  of  the  genital 
tract,  namely,  of  the  lower  uterine  segment,  the  cervix,  vagina,  and  perineum. 
Another  important  cause,  not  often  taken  into  account,  is  (c)  insufficient  con- 
traction of  the  lower  uterine  segment  in  cases  of  low  implantation  of  the  placenta. 
Here,  while  the  fundus  contracts  firmly  and  completely,  an  imperfectly  contracted 
lower  segment  permits  of  fatal  hemorrhage  from  the  open  blood-vessels  of  the 
low-situated  placental  site,  (d)  Partial  or  complete  inversion,  although  a  most 
infrequent  cause,  must  be  enumerated ;  and  the  likelihood  of  fibroids  of  the  uterus 
or  cancer  of  the  genital  tract  must  be  borne  in  mind. 


PART   SIX, 


Physiological  Puerperium*     The  Puerperal 

Woman* 


DEFINITION.     INTRODUCTION. 

I.  GENERAL  PHENOMENA,  (Page  673.)  Exhaustion.  Chills.  After-pains. 
Pulse.  Temperature.  Respiration.  Skin.  Kidneys.  Muscles.  Blood. 
Heart.      Weight.     Psychical  Changes. 

H.  LOCAL  PHENOMENA.  (Page  677,)  External  Genitals,  Vagina.  Cervix 
and  Cervical  Canal.  Lochia.  Bladder.  Involution.  (1)  Height  of 
Fundus.  (2)  Uterine  Muscles.  (3)  Vessels.  (4)  Decidua.  (5)  Placental 
Site.  (6)  Adnexa.  Alterations  in  Mammae  and  Milk  Secretion.  Sub- 
sequent Impregnation. 

HL  DIAGNOSIS  OF  THE  PUERPERIUM,  (Page  687.)  1,  Signs  of  Recent 
Delivery  in  the  Living  and  the  Dead.  2.  Primipara  and  Multiparas 
Feigned  Lying-in  State. 

IV.  MANAGEMENT  OF  THE  PUERPERIUM.  (Page  688.)  1.  Introduction. 
2.  Asepsis.  3.  Rest.  4.  Professional  Visits.  (1)  Temperature.  Pulse. 
Respiration.  (2)  Height  and  Condition  of  the  Uterus.  (3)  The  Lochia, 
(4)  External  Genitals.  (5)  Bladder.  (6)  The  Bowels.  (7)  (8)  The  Breast, 
and  Nipples.  5.  Diet.  6.  Posture  and  Duration.  7.  Prophylaxis.  (1) 
Abdominal  Binder.  (2)  Pelvic  Binder.  (3)  Medication.  (4)  Massage 
and  Exercise.  (5)  The  First  Use  of  the  Corset.  8.  The  Examination 
of  the  Puerperium. 


Definition. — The  puerperium  is  the  period  from  the  completion  of  the  third 
stage  of  labor  to  the  time  when  the  uterus  has  returned  to  its  normal  dimensions. 
Its  duration  is  six  weeks  or  more. 

Introduction. — The  size  of  the  uterus  at  the  fortieth  week  is  12  inches  X 
9  inches  X  8j  inches;  its  weight  two  poim.ds,  and  capacity  400  cubic  inches 
The  size  of  the  uterus  at  the  end  of  the  puerperium  is  3^  inches  X  zh  inches 
X  i^  inches;  its  weight  an  ounce  and  a  half  to  two  ounces,  and  capacity  one 
cubic  inch.  The  changes  which  go  on  in  the  uterus  and  its  adnexa  during 
this  period  and  that  bring  about  the  above  results  are  known  as  the  changes 
of  involution.  The  process  is  a  physiological  one,  but  closely  borders  on  the 
pathological.  To  understand  this  we  have  only  to  remember  (i)  the  absorption 
of  two  pounds  of  uterine  tissue;  (2)  the  formation  of  thrombi  in  the  uterine 
walls;  (3)  the  rapid  cell  production  upon  the  internal  surface  of  the  uterus; 
(4)  the  atrophy  and  fatty  metamorphosis  in  the  uterine  walls;  (5)  the  tearing 
across  of  blood-vessels  at  the  placental  site,  leaving  large  raw  surfaces  with 
the  dangers  of  septic  absorption;  and,  finally,  (6)  in  most  cases,  including 
all  primiparas,  the  actual  traumatic  lesions  in  the  nature  of  contusions  and 
lacerations  of  the  cervix,  vagina,  and  vulva. 


I.  GENERAL  PHENOMENA. 

Exhaustion. — The  action  of  the  recuperative  forces  of  nature  is  seen  to 
great  advantage  after  normal  labor.  As  a  rule,  the  patient  recovers  from 
the  trying  ordeal  much  more  rapidly  than  would  be  expected,  and  in  the  absence 
of  excessive  hemorrhage  or  septic  infection,  this  is  usually  the  case  even  after 
severe  and  protracted  labors  and  operative  delivery.  Immediately  after 
delivery  there  is  a  natural  tendency  to  rest  and  sleep,  and  from  this  repose 
the  woman  wakes  in  a  state  of  perspiration  and  much  refreshed  and  strengthened. 
Nervotis,  irritable  women,  however,  do  not  readily  fall  asleep  at  this  period. 
More  or  less  thirst  is  present,  due  to  increased  excretion  by  the  skin  and  kidneys, 
with  a  certain  amount  of  burning  pain  in  the  external  genitals,  depending 
upon  birth  traumatisms. 

The  Post-partum  Chill. — A  chill  of  short  duration,  but  which  may  be  pro- 
nounced in  character,  frequently  follows  the  completion  of  labor.  The  pulse 
and  temperature  are  not  altered  and  the  chill  is  not  of  clinical  importance. 
It  is  most  frequently  observed  after  rapid  labors,  and  is  probably  due  to  the 
internal  congestion  caused  by  the  sudden  decrease  in  the  intra-abdominal 
pressure  which  causes  a  rapid  recession  of  blood  from  the  surface  of  the  body. 
The  chill  disappears  without  treatment,  but  something  can  be  done  to  aid 
the  recovery  of  the  circulatory  equilibriimi  by  covering  the  patient  with  warm 
blankets.  The  chill  may  also  be  due  to  the  wetting  of  the  surface  by  perspira- 
tion, blood,  and  amniotic  fluid;  to  the  sudden  cessation  of  muscular  effort  ;  to 
loss  of  blood,  or  to  withdrawal  of  the  warm  fetus  and  placenta. 
43  673 


674 


PHYSIOLOGICAL  PUERPERIUM. 


After-pains. — Post-partum  contractions  which  continue  for  several  days  into 
the  puerperium  are  frequently  seen  in  practice  and  are  quite  painful  at  times. 
They  may  occur  spontaneously  or  only  when  the  child  is  applied  to  the  breast. 
They  appear  more  commonly  on  the  first  than  on  the  second  day  and  affect 
multiparas  by  preference.  When  a  primipara  has  after-pains,  they  occur,  as 
a  rule,  as  a  sequel  to  some  particular  type  of  labor,  such  as  involves  precipitate 
delivery,  or  previous  overdistention  of  the  uterus,  i.e.,  twins  or  hydramnios. 
They  are  also  associated  at  times  with  the  retention  of  blood-clots  and  decidual 
structures.  While  the  same  factors  may  be  present  in  the  after-pains  of  mul- 
tiparas, they  are  often  notably  absent. 

Pulse. — With  the  rapid  fall  in  arterial  tension  which  occurs  during  and 
after  delivery  there  is  a  marked  diminution  in  the  frequency  of  the  pulse.  From 
60  to  70  is  about  the  normal  rate  after  delivery,  and  occasionally  it  is  even 
less.  A  rapid  pulse  at  this  time  should  lead  the  attendant  to  suspect  the  exist- 
ence of  hemorrhage  or  some  other  complication.  I  found  the  pulse  in  141 7 
observations  one  hour  after  delivery  as  follows : 


40  t( 

3  50 

m    2 

cases. 

100 

to   no 

m 

48 

=;o   ' 

60 

13 

110 

120 

23 

60  ' 

70 

345 

120 

"  130 

3 

70  ' 

So 

"   566 

" 

130 

140 

2 

80  • 

90 

302 

140 

150 

.  2 

90 

100 

1 10 
Total 

160 
141 

7 

cases. 

I 

The  pulse  of  the  normal  puerperium  is  slow  and  soft,  and  often  irregular  and 
intermittent.  It  is  also  very  irritable  and  easily  accelerated  by  trivial  causes. 
But  these  qualities  are  by  no  means  constant  in  all  puerperae,  at  least  in  notable 
degrees.  Temesvary  states  that  a  slow  pulse  occurs  in  but  60  per  cent,  of 
normal  puerperal  women.  In  certain  cases  the  pulse-rate  falls  to  36,  32,  even 
to  30  beats  per  minute.  The  frequency  before  delivery  is  about  86,  while 
the  average  frequency  throughout  the  puerperal  period  is  about  63,  so  that 
the  result  of  delivery  is  a  reduction  in  the  pulse-rate  of  over  20  beats.  Imme- 
diately after  delivery  the  pulse  falls  to  about  72,  but  after  irregular  labors 
not  below  75.  The  rate  now  sinks  a  little  each  day  until  it  arrives  at  a  minimum 
(average  57)  on  the  eighth  day.  It  remains  at  this  level  until  a  period  near 
the  end  of  the  second  week,  when  it  begins  to  rise  again  until  it  attains  its 
normal  level.  This  tendency  to  a  lowering  of  the  pulse-rate  is  antagonized 
by  hemorrhage  or  fever  from  any  cause ^  so  that  a  pulse-rate  of  moderate 
frequency  early  in  the  puerperium  may  or  may  not  have  an  unfavorable  sig- 
nificance. As  the  effects  of  the  complications  wear  away,  the  slowing  of  the 
pulse  may  assert  itself  later  in  the  puerperal  period.  When  a  slow  puerperal 
pulse  becomes  accelerated  without  evident  cause,  we  should  fear  possible  em- 
bolism of  the  lungs.  The  causes  of  the  slow  pulse  of  the  puerperal  period 
are  still  unknown.  It  is  likely  that  several  factors  co-operate  to  produce  this 
result.  One  is  the  absolute  rest  in  bed,  another  the  lowering  of  the  arterial 
tension,  a  third  the  relief  of  the  lungs  which  leads  to  slowing  of  the  respiration, 
etc.  But  if  these  factors  alone  were  the  occasion  of  a  slow  pulse,  the  latter 
should  be  common  to  all  puerperce.  The  absence  of  constancy  in  this  respect 
appears  to  point  to  the  nervous  system,  which  shows  such  individual  peculiarities, 
as  largely  responsible.  Certain  unknown  factors  may  produce  the  slow  pulse 
through  the  vagus  nerve  or  accelerator  nerves  of  the  heart.  The  apex  of  the 
heart  is  lowered  nearly  f  inch  (2  cm.)  after  expulsion  of  the  f^us,  and  a  slight 
impurity   of  the    first  sound  manifested    by    a   blowing  murmur   persists   for 


.GENERAL  PHENOMENA.  675 

about  a  week  in  about  three-fourths  of  all  puerperae.  The  uterine  soufifle  has 
been  found  to  last,  on  an  average,  about  fifty-six  hours  after  delivery,  and  con- 
siderably longer  if  the  puerperium  is  abnormal.  It  is  less  marked  than  during 
pregnancy  and  its  persistence  beyond  a  certain  period  shows  a  delay  in  the 
process  of  involution. 

Temperature. — This  is  slightly  raised  by  the  act  of  labor,  so  that  the  measure- 
ments taken  just  before  and  just  after  labor  should  exhibit  a  certain  difference. 
This  physiological  increase  is  not  to  be  confounded  with  a  considerable  elevation 
seen  in  individual  cases,  which  lasts  but  a  short  time,  and  which  is  attributable 
to  constipation,  a  disordered  stomach,  or  mental  influence.  The  physiological 
rise  averages  about  0.48°  F.  (0.27°  C).  For  the  first  six  or  seven  hours  after 
delivery  the  temperature  continues  elevated,  and  then  sinks  slowly,  so  that 
considerably  before  the  expiration  of  the  first  twenty-four  hours  it  has  returned 
to  the  ante-partum  point.  The  temperature  curve  is  the  same  in  primiparae 
and  multiparse.  It  varies  slightly  with  the  period  of  the  day  at  which  delivery 
occurs.  The  normal  rise  of  temperature  in  the  puerperium  is  attributed 
by  Temesvary  to  the  changes  in  the  circulation  which  follow  expulsion  of  the 
child,  there  being  an  increase  of  pressure  in  the  capillaries  of  the  kidneys,  liver, 
lungs,  and  skin.  While  the  temperature  is  practically  normal  after  the  first 
day,  there  is  a  very  slight  constant  daily  fluctuation  throughout  the  first  few 
days,  which  is  doubtless  dependent  upon  the  secretion  of  milk.  In  1420  obser- 
vations of  the  temperature  one  hour  after  labor  I  obtained  the  following  table : 

Temperature,   97.0°  F.  to     98.4°  F.  in  380  cases. 


98.5°  F.  "  98.4°  F. 

99.5°  F.  "  100.4°  F. 

100.5°  F-  "  101.4°  F. 

101.5°  F-  "  102.4°  F. 


748 

255 
29 

4 


102.5°  F.  "  103.4°  F.  '; 4 

Total 1420  cases. 

Respiration. — After  delivery  the  rate  of  respiration  is  lowered,  and  may 
be  anywhere  between  14  and  20.  The  vital  capacity  is  increased.  An  equi- 
librium is  reached  at  about  the  third  or  fourth  day.  The  type  of  respiration 
either  continues  to  be  thoracic  from  the  habit  acquired  in  pregnancy,  or  it 
becomes  abdominal  or  mixed.  The  expired  air  contains  a  larger  proportion 
of  water  and  carbon  dioxid  than  normal.  This  fact  may  be  readily  appreciated 
in  a  hospital  ward  full  of  recently  delivered  women  if  the  ventilation  is  not 
of  the  best.  I  found  the  respirations  in  11 73  cases  one  hour  after  delivery 
as  follows: 


Respirations, 

15  to  20  in  486  case 

20    "    25    "    461 

25    "    30    "    186 

30    "    35    "      23       " 

35    "    40    "      14 

40    "    45    "        2 

55    "    60    "        I  case. 

Skin. — The  free  perspiration  of  the  first  four  or  five  days  of  the  puerperium 
is  due  undoubtedly  to  the  increase  in  metabolism  which  is  connected  with  uterine 
involution  and  the  puerperal  loss  of  weight.  This  active  sweating  exposes  the 
woman  to  colds,  and  she  must  be  carefully  protected  from  overheating,  sudden 
cooling,  draughts,  etc.  The  functions  of  the  skin  become  normal  at  the  end 
of  the  first  week.  The  sweating  is  accompanied  by  abundant  desquamation, 
which  aids  in  the  disappearance  of  the  pigmentation  and  oedema  of  pregnancy. 
The  puerperal  sweat  is  rich  in  butyric  acid. 


676  PHYSIOLOGICAL  PUERPERIUM. 

Stomach  and  Bowel. — The  puerperal  woman  appears  to  have  Httle  inclination 
for  solid  food  until  lactation  is  established,  after  which  the  appetite  becomes 
awakened.  Digestion  is  slow  throughout  the  puerperium  and  indigestion 
is  readily  provoked.  These  peculiarities  appear  to  be  due  to  the  readjustment 
of  the  gastro-intestinal  tube  following  the  expulsion  of  the  child.  Thirst  is 
often  notably  increased  at  the  outset  of  the  puerperium.  A  spontaneous  move- 
ment of  the  bowels  seldom  occurs  during  the  earliest  puerperal  days.  The 
bowels  have  generally  been  evacuated  thoroughly  before  delivery,  and  but 
little  nutriment  is  taken  until  some  hours  after  this  event;  the  intra-abdominal 
pressure  is  reduced  to  a  minimum  and  the  natural  peristalsis  is  much  depressed; 
the  woman  is  in  perfect  repose  in  the  recumbent  position;  the  perspiratory 
function  is  highly  augmented,  to  say  nothing  of  the  activity  of  the  kidneys, 
the  lochial  discharge,  and  the  beginning  secretion  of  milk.  Through  the 
coincidence  of  all  these  factors  a  natural  stool  would  be  almost  an  impos- 
sibility. 

Kidneys. — During  the  first  few  hours  after  delivery  there  is  usually  little 
desire  for  urination,  owing  to  a  paretic  state  of  the  muscles  of  the  bladder,  the 
result  of  the  strong  compression  during  the  expulsion  of  the  child.  The  early 
urine  is  concentrated.  An  important  fact  in  the  physiology  of  the  puerperium 
is  the  length  of  time  which  the  patient  can  retain  her  urine  without  any  sensa- 
tion of  repletion.  In  the  statistics  of  Temesvary  35  per  cent,  of  the  women 
went  from  twelve  to  twenty-four  hours  without  a  spontaneous  passage  of 
urine,  and  in  6  per  cent,  this  interval  was  prolonged  to  a  period  between  twenty- 
four  and  thirty-six  hours.  The  amount  of  urine  which  collects  in  the  bladder 
during  these  protracted  intervals  is  considerable.  Catheterization  under  these 
circumstances  is  not  desirable,  and  should  be  replaced  by  gentle  frictions  over 
the  bladder,  warm  wet  compresses  or  poultices,  or  simple  elevation  of  the 
upper  part  of  the  trunk.  (See  Treatment.)  The  quantity  of  urine  passed  daily 
during  the  first  puerperal  week  is  larger  than  that  voided  by  the  non-pregnant 
woman,  but  considerably  less  than  the  amount  secreted  during  the  last  weeks 
of  pregnancy.  In  the  first  day  or  two  of  the  puerperium  the  amount  of  urine 
is  increased  over  that  of  subsequent  days,  and  the  density  should  be  below 
1020;  after  the  third  day  it  is  usually  above  1020.  An  increase  in  the 
amount  of  urea  excreted  during  the  lying-in  period  is  attributed  to  the 
process  of  involution.  Albumin  occurs  in  the  urine  of  many  puerperal  women, 
not  reckoning  cases  of  albuminuria  of  pregnancy.  This  is  the  result  of  the 
renal  stasis  which  results  from  the  act  of  labor.  After  the  first  twenty- 
four  hours  albumin  should  disappear  from  the  urine.  If  the  woman  had 
albuminuria  before  pregnancy,  the  urine  does  not  clear  up  until  toward 
the  close  of  the  first  week.  Sugar  (lactose)  is  found  in  the  urine  whenever 
there  is  any  impediment  to  the  secretion  of  milk,  as  in  cases  in  which  the  child 
does  not  nurse  sufficiently.  But  this  stops  abruptly  if  the  woman  does  not 
nurse  her  child  at  the  outset.  The  percentage  of  sugar  is  greatest  at  about 
the  fourth  or  fifth  puerperal  day.  Peptonuria  attributed  to  the  involution 
of  the  pregnant  uterus  begins  in  the  second  half  of  the  first  puerperal  day 
and,  as  a  rule,  lasts  four  or  five  days.     This  phenomenon  is  not  constant. 

Muscles. — The  muscular  fatigue  and  the  semi-paretic  state  of  certain  muscles 
which  result  from  the  act  of  labor  disappear  promptly,  as  a  rule;  but  exception- 
ally they  last  for  days  or  even  weeks.  The  woman  has  a  somewhat  similar 
experience  when  she  first  gets  up,  but  this  also  rapidly  disappears.  Delicate 
women  often  exhibit  an  unnatural  degree  of  mobility  of  the  pelvic  articu- 
lations.- 


LOCAL  PHENOMENA.  677 

The  Blood. — It  was  formerly  supposed  that  the  watery  elements  of  the 
blood  were  increased  during  pregnancy,  while  the  hemoglobin  and  red  cor- 
puscles were  relatively  diminished.  Later  investigations  have  tended  to  dis- 
prove this  statement.  The  decrease  in  hemoglobin  and  red  corpuscles  observed 
after  delivery  is  probably  due  to  hemorrhage,  which  occurs  even  in  normal 
cases.  The  hyperinosis  of  pregnancy  is  increased  during  the  puerperium  owing 
to  the  presence  of  effete  material  in  the  circulation.  The  number  of  leucocytes 
in  the  blood  is  at  a  maximum  during  the  third  stage  of  labor.  It  sinks  rapidly 
after  delivery  and  attains  a  minimum  at  about  the  twelfth  hour  of  the  puerperal 
period.  It  begins  to  increase  on  the  second  day  or  a  little  later,  to  undergo 
another  reduction  when  the  secretion  of  milk  has  become  established.  The 
number  of  red  blood-corpuscles  and  the  proportion  of  hemoglobin  also  undergo 
a  diminution  after  delivery,  dependent  in  degree  upon  the  amount  of  blood 
lost  during  labor.  This  reduction  is  followed  by  an  increase,  so  that  by  the 
end  of  the  first  puerperal  week  the  blood  is  of  the  same  quality  as  before  de- 
livery. 

The  Heart. — In  normal  cases  the  heart  speedily  adapts  itself  to  the  decreased 
arterial  tension  and  diminished  volume  of  blood.  It  has  been  asserted  that 
in  consequence  of  the  extra  work  required  during  pregnancy  a  hypertrophy 
of  the  left  ventricle  takes  place  which  disappears  after  delivery,  but  this  is 
not  proved.     (Compare  Physiological  Pregnancy,  Part  II.) 

Weight. — During  the  first  week  there  is  loss  of  weight  consequent  upon 
the  diminished  appetite,  the  increased  excretions  by  the  skin,  and  the  normal 
retrograde  changes  in  the  intra-pelvic  viscera  attendant  upon  the  process 
of  involution.  The  loss  is  estimated  at  nine  or  ten  pounds.  In  addition  to  the 
loss  of  weight  through  the  act  of  labor  itself,  there  is  a  further  loss  which  results 
from  the  great  activity  of  the  various  secretions,  the  lochial  discharge,  involution 
of  the  uterus,  absorption  of  oedema,  etc.  But  with  a  proper  amount  of  nourish- 
ment the  reduction  is  not  excessive.  Equilibrium  in  weight  is  reached  in 
about  six  or  eight  weeks,  when  it  corresponds  to  the  average  before  conception. 
In  primiparse,  after  twin  pregnancies,  and  in  women  who  do  not  nurse  their 
children  the  loss  in  weight  is  proportionately  greater.  Delicate  women  may  not 
regain  their  normal  weight  for  months. 

Nervous  System. — During  the  first  few  days  of  the  puerperium  the  woman 
is  in  a  condition  of  irritable  weakness  which  involves  the  special  senses  and 
the  mind.  This  condition  is  aggravated  by  after-pains  and  by  attempts  of 
the  child  to  nurse,  etc.  Mental  excitement  sometimes  leads  to  rise  of  tem- 
perature (see  Fever,  Part  VI),  sleeplessness,  and  other  ill  effects.  It  is  self- 
evident  that  every  source  of  annoyance  should  be  avoided. 


II.  LOCAL  PHENOMENA. 

External  Genitals. — After  delivery  the  external  genitals  are  bruised  and 
swollen  and,  especially  in  primiparas,  are  the  seat  of  various  abrasions  and  lacera- 
tions. There  is  gaping  of  the  labia  majora  and  minora,  and  if  labor  has  been 
prolonged  considerable  oedema  may  be  present  (Fig.  467).  The  vulva  and 
perineum  lose  their  secretions  through  absorption  of  the  infiltration;  the  vari- 
cosities in  the  veins  diminish,  and  pigmented  areas  fade  out.  The  various  super- 
ficial and  deep  contusions  and  lacerations  gradually  disappear,  healing  by  epithe- 
lial migration,  leaving  whitish  scars.     In  primiparas,  in  addition,  the  remains  of 


678 


PHYSIOLOGICAL  P UERPERI UM. 


the  hymen  undergo  necrosis  with  the  persistence  of  the  so-called  camncular  for- 
mations (Fig.  28).  The  abdomen  remains  wrinkled  and  pendulous  for  weeks  and 
never  regains  its  original  appearance.  Striae  atrophicae  are  often  apparent, 
dating  from  pregnancy. 

Vagina. — The  vagina  is  at  first  relaxed,  its  mucous  membrane  is  smooth  and 
flabby  and  the  rugas  are  absent.  In  a  few  weeks  it  very  nearly  regains  its  normal 
condition.  It  becomes  narrower  and  shorter,  although  it  never  returns  to  its 
original  dimensions.  The  folds  which  were  effaced  by  the  act  of  labor  form 
anew,  but  never  acquire  their  original  number  or  sharpness  of  contour.  The 
ostium  vaginas  tends  to  remain  somewhat  patulous,  especially  behind,  and  a 
certain  prolapse  of  the  vaginal  walls  within  the  ostium  is  often  present.  The 
process  of  involution  goes  on  more  rapidly  near  the  ostium  vaginae  than  in  the 
upper  portion. 

Cervix  and  Cervical  Canal. — The  cervix  after  delivery  is  much  distorted,  but 
the  external  OS  can  always  be  recognized  (Figs.  531  and  636).  'Lacerations  at  this 
point  are  usually  present.     The  cervix  and  vagina  cannot  at  first   be  clearly 


Fig.  907. — Lochia  on  the 
Second  Day  of  the 
PuERPERiuM.  I,  2,  Epi- 
thelium; 3,  4,  white  blood- 
corpuscles;  5,  red  blood- 
corpuscles;  6,  decidual 
cell.— (Winckel.) 


Fig.  908. — Lochia  on  the 
Fourth  Day  of  the 
PuERPERiuM.  I,  Decid- 
ual cell;  2,  white  blood- 
corpuscles;  3,  red  blood- 
corpuscles;  4,  epithelium; 
5,  micro-organisms.  — 
(Winckel.) 


Fig.  939. — Lochia  on  the 
Seventh  Day  of  the 
Puerperium;  Afebrile 
Case,  i,  Red  blood-cor- 
puscles; 2,  diplococci  and 
monococci;  3,  white  blood- 
corpuscles;  4,  epithelium; 
5,  decidual  cells. — (Win- 
ckel.) 


distinguished  from  each  other,  but  after  twelve  hours  the  distinction  becomes 
marked.  At  the  tenth  day  post  partum  the  internal  os  admits  the  passage 
of  the  index-finger  readily  in  about  60  per  cent,  of  primiparae  and  about  70  per 
cent,  of  multiparae,*  but  soon  thereafter  closes.  The  external  os  admits  the 
finger  much  longer  and  never  exactly  regains  its  former  condition.  Immediately 
after  delivery  the  cervix  gapes,  and  the  canal  is  so  patulous  that  it  will  accom- 
modate half  the  hand.  This  condition  rapidly  changes  through  thickening  of 
the  cervical  wall,  the  cervical  folds  reappear  at  the  same  time,  and  by  the 
twelfth  day  its  involution  is  almost  complete.  On  the  contrary,  the  portio 
vaginalis  requires  some  five  or  six  weeks  to  regain  its  original  condition.  The 
lips  of  the  external  os  immediately  after  delivery  project  into  the  vagina  as  soft 
tumors.  If  the  anterior  lip  has  been  incarcerated  during  labor,  it  may  reach 
as  far  as  the  vulva. 

The  Lochia. — By  this  term  is  understood  the  utero-vaginal  discharge  which 
continues  for  two  or  more  weeks  after  delivery.  For  the  first  three  or  four  days 
it  is  called  the  lochia  rubra  (red  lochia),  and  consists  principally  of  blood  and 

*  Author's  observation  of  several  hundred  cases. 


LOCAL  PHENOMENA. 


679 


blood-clots  with  some  admixture  of  the  epithelial  elements  of  the  vagina  and 
cervix  and  fragments  of  decidua  (Fig.  907).  For  the  next  three  or  four  days  it 
is  mainly  serous  in  character  and  is  called  the  lochia  serosa  {serous  lochia) 
(Fig.  908).  After  this,  as  the  separation,  disintegration,  and  casting-off  of  the 
products  of  involution  go  on,  it  becomes  thicker  and  whiter  in  color  and  is 
called  the  lochia  alba  (white  lochia)  (Fig.  909).  It  contains  disintegrated  tis- 
sues of  the  birth  canal,  the  secretions  from  granulating  wounds,  and  micro- 
organisms, which,  it  should  be  noticed,  are  not  found  for  the  first  day  or 
two,  are  confined  to  the  vaginal  secretions,  and  under  ordinary  circum- 
stances do  no  harm.  In  normal  conditions  the  uterine  lochia  is  to  be 
regarded  as  sterile.  The  amount  of  the  discharge  has  been  estimated  as 
follows:  For  the  first  four  days  2^  pounds  (i  kilo);  for  the  second  two  davs, 
about  9  ounces  (256  gm.);  until 
the  ninth  day,  nearly  7  ounces 
(199  gm.).  Under  ordinary  circum- 
stances if  more  than  one  change  of 
napkins  is  needed  every  four  hours 
for  the  first  few  days,  the  amount 
is  to  be  regarded  as  excessive. 
After  the  first  two  or  three  days 
the  lochia  has  a  peculiar  sickish, 
but  not  putrid,  odor.  It  is  import- 
ant that  the  physician  should  be 
familiar  with  this  odor  in  order  that 
he  may  recognize  a  departure  from 
the  normal  and  that  odorless  vulval 
dressings  be  employed.  The  dis- 
charge is  more  profuse  in  multi- 
parae  than  in  primiparee  and  in 
women  who  do  not  nurse  their 
children  than  in  those  who  do.  A 
diminution  in  the  usual  amount  of 
the  discharge  should  be  regarded 
with  suspicion.  Suppression  is 
often  a  sign  of  sepsis. 

The  Bladder. — Owing  to  the  in- 
creased quantity  of  urine,  the  sud- 
den decrease  of  intra-abdominal 
pressure,  reflex  urethral  spasm,  the 
bruising  and  swelling  of  the  tis- 
sues, and  especially  to  the  recumbent  position,  retention  of  urine  frequently 
occurs. 

Involution. — After  the  expulsion  of  the  fetus  and  secundines  the  uterus 
contracts  upon  itself,  so  that  the  fundus  is. below  the  level  of  the  umbilicus. 
Immediately  after  delivery  examination  reveals  a  mass  equal  to  that  of  a  preg- 
nant uterus  at  the  twentieth  week.  Its  weight  is  26  to  35  ounces  (750  to  1000 
gm.);  length  6.3  to  7  inches  (16  to  18  cm.);  length  of  cavity  5.9  inches  (15  cm.); 
thickness  of  wall  0.98  to  1.57  inches  (25  to  40  mm.).  At  the  eighth  day  of  the 
puerperium  the  mass  of  the  uterus  should  be  reduced  one-half.  Thus,  the 
weight  after  delivery  is  26  to  35  ounces  (750  to  1000  gm.) ;  at  eighth  day,  14.9  to 
17.6  ounces  (400  to  500  gm.);  on  the  fourteenth  day,  13  ounces  (350  gm.);  on  the 
fourth  week,  7.5  ounces  (200  gm.).     Finally,  at  the  end  of  two  months  the  uterus 


SHD   of  First  D^y 


SYMPHYSIS 


Fig.    910. — Height    of    the 
THE  First  Ten  Days  of 


—  {From  the  author's  measurements.) 


Fundus    during 
THE  Puerperium. 


680 


PHYSIOLOGICAL  PUERPERIUM. 


has  regained  its  original  weight  of  1.85  to  2.78  ounces  (50  to  75  gm.)  and  length 
of  2.95  inches  (7  cm.).  I  found  the  length  of  the  uterine  cavity  from  the  external 
OS,  measured  with  a  sound  on  the  tenth  day  of  the  puerperium  in  119  primiparae, 
3.21  inches  (8.15  cm.),  and  in  99  multiparse  3.53  inches  (8.97  cm.).*  The  first 
step  in  involution  is  the  permanent  contraction  of  the  uterus,  which  should 

occur  about  one  and  a  half 
or  two  hours  after  the  birth 
of  the  child  and  immediately 
after  the  expulsion  of  the 
placenta.  Active  contrac- 
tions are  succeeded  by  a 
period  of  retractility  due  to 
the  natural  resiliency  of  the 
uterine  wall  and  muscular 
tonus.  This  is  also  exerted 
during  the  period  of  active 
contraction  in  such  a  man- 
ner that  each  active  post- 
partum contraction  effects 
an  absolute  and  permanent 
reduction  in  the  size  of  the 
uterus.  It  is  due  to  the  per- 
sistence of  this  retractility 
that  involution  becomes 
possible.  Uterine  retractil- 
ity is  under  the  influence  of  the  central  nervous  system,  as  shown  by  its  inhibition 
under  the  influence  of  mental  emotion  even  late  in  the  puerperium.  Its  arrest 
under  these  conditions  may  be  accompanied  by  secondary  hemorrhage.  The 
amount  and  character  of  nutriment  and  the  rate  of  metabolism  are  also  known 
to  modify  the  process  of  involution,  which  goes  on  more  slowly  by  night  than  by 


Fig.  911. — Puerperal  Uterus  Fifty-three  Hours 
Post  Partum.  Normal  Puerperium. — {Modified 
from  Sellheim.) 


Thnrmms. 
Blood Qot  mUtCainn 
Transverse 
andOUtoue  muxleBum/ies 

Boundary  , 

lose  attachment  of  Pentoneim 
l/terv-ves.7>oucfi 

eattacfimenz/i/?  _ 
Paiiomum  •' 

PoitVagJomix 
Oouglm  pouch 

Hectum 

Hertun 


AniVag. /orniK, 
Prepuce  qf  Clitoris 
aitoris 

Vrethra 
Laiium  minus 
Vayina 
Vaq.  portion  Of  Cervix 
f^nneum 
Ext  Sp/uniterAm. 
Int.  SphinOerAni 
W-^^.  _   Ru^oas  muaiusMejn.0/ Rectum 
Anus 

Ext.  SphinclerAnL 


Fig.  912. — Sagittal  Section  of  a  Puerperal  Uterus  Fifty-three  Hours  Post  Partum. 

Normal   Puerperium. — {Sellheim.) 


day.  The  uterus  in  which  involution  is  already  under  way  may  still  undergo 
active  contractions  (after-pains)  from  reflex  stimulation  by  the  nursing  child. 
The  uterus  is  known  to  be  slightly  smaller  just  after  delivery  than  at  the  com- 
pletion of  the  first  three  puerperal  days.     This  is  due  to  the  manipulation  of  the 

*  If  the  practitioner  wishes  to  estimate  the  progress  of  involution  with  the  sound,  the 
bladder  should  first  be  completely  emptied. 


LOCAL  PHENOMENA. 


681 


uterus  in  connection  with  the  third  stage  of  labor  and  the  early  post-partum 
hours,  producing  an  initial  reduction  in  size  which  is  followed  by  a  slight  reac- 
tion. Measurements  of  the  height  of  the  fundus  above  the  symphysis  during 
the  early  puerperal  days  are  as  follows. 

Ci)  Height  of  Fundus. — From  careful  measurements  taken  in  321  primi- 
paras  and  709  multiparae,  during  non-febrile  puerperia,  I  found  the  height  of  the 
fundus  above  the  symphysis  to  be  as  follows: 


TABLE  OF  HEIGHT  OF  FUNDUS  ABOVE  SYMPHYSIS.* 


Time. 


321  Primipar^, 
Average  Height. 


Immediately     after 

third  stage 5.93 

First  day ;  6.06 

Second  day \  4.61 

Third  day   

Fourth  day 

Fifth  day 

Sixth  day 

Seventh  day 

Eighth  day 

Ninth  day 

Tenth  day 


709  Multipara, 
Average  Height. 


5-92 

in.    ( 

.=;-3.=; 

m.    ( 

4 

66 

m.    ( 

4 

26 

m.    ( 

.3 

68 

in.    ( 

3 

27 

m.    ( 

2 

97 

m.    ( 

2 

89 

m.    ( 

2 

60 

m.    ( 

2 

10 

m.    ( 

I 

96 

in.    ( 

(15.10 

(13.60 

(11.50 

(10.79 

(  9-20 

(  8.30 

(  7-5° 
(  7-40 
(  6.45 
(  5-3° 
5.00 


cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.). 


Total  Average. 


5-92 
5-7° 
4-63 

4  37 
3-75 
3.20 

3-42 
2.90 
2-55 
2.32 
2.22 


15-8 
12.90 
11.30 
II. 10 
9-52 
8.00 


cm.), 
cm.), 
cm.), 
cm.) . 
cm.), 
cm.). 


8.48  cm.). 

7.40  cm.). 

6.40  cm.). 

6.00  cm.), 

5.60  cm.). 


Statistics  of  the  width  of  the  uterus  show  a  corresponding  diminution.  During 
the  first  two  puerperal  days  the  width  is  greater  than  immediately  after  de- 
livery. Upon  the  tenth  day  post  partum  the  uterus  does  not  lie  entirely  in 
tlie  true  pelvis,  as  is  so  often  stated.  My  observations  show  that  in  primiparce 
the  fundus  on  the  tenth  day  is  still  2.49  inches  (6.34  cm.)  above  the  symphysis, 
and  in  multiparae  1.96  inches  (5.00  cm.) — a  total  average  of  2.22  inches  (5.60 
cm.).  While  its  position  at  the  onset  of  the  puerperium  is  one  of  retrodis- 
placement  (Fig.  912)  as  a  result  of  its  weight  and  the  laxity  of  its  ligaments,  the 
conditions  are  reversed  in  involution,  so  that  by  the  ninth  day  the  position 
is  one  of  anteversion  or  anteflexion,  which  increases  as  involution  progresses 
(Fig.  911).  A  certain  degree  of  rotation  on  the  longitudinal  axis  is  often  pres- 
ent. Hansen  (cited  by  Temesvary)  has  made  measurements  which  show  that 
the  distance  from  the  fundus  to  the  external  os  diminishes  up  to  the  tenth 
week  post  partum.  These  figures  appear  to  be  a  suitable  criterion  for  the 
duration  of  the  process  of  involution.  They  also  show  that  the  uterus  never 
entirely  regains  its  original  length.  By  this  means  it  may  also  be  shown  that 
involution  occurs  with  less  delay  in  multiparae  and  nursing  mothers.  Involution 
is  also  known  to  be  delayed  after  hydramnios,  twin  births,  labor  in  contracted 
pelves,  hemorrhage,  premature  delivery,  puerperal  disease,  and  the  action  of 
psychical  influences. 

(2)  Muscle. — We  know   that   the   original  muscular   fibers  of  the  uterus 

*  Temesvary  gives  the  following  table: 

Immediately  after  delivery    4.29  inches  (10.91  cm.). 

First  day ' 5.33  "  (13.55  cm.). 

Second  day 4.9  "  (12.45  cm.). 

Third  day 4-39  "  (11. 16  cm.). 

Fourth  day 4.02  "  (10.21  cm.). 

Fifth  day 3.66  "  (  9.29  cm.). 

Sixth  dav 3.24  "  (  8.22  cm.). 

Seventh  day 3.00  "  (  7.61  cm.). 

Eighth  day' '2. 88  "  (  7.32  cm.) 


682 


PH  Y SI  0  LOGIC  A  L  P  UERPERI UM . 


increase  in  size  during  gestation.  Therefore  in  involution  the  hypertrophied 
individual  elements  must  undergo  reduction  to  their  normal  dimensions.  This 
is  effected  by  fatty  metamorphosis  of  the  protoplasm  of  the  muscle- fibers.  The 
primitive  fat-drops  coalesce  to  form  large  collections  between  the  muscular  bun- 
dles, whence  the  fat  is  taken  up  by  the  blood-  and  lymph-capillaries.  The  appear- 
ance of  fat-drops  in  the  uterine  muscle-cells  is  an  evidence  on  the  first  day  post 
partum.  The  process  of  involution  affects  the  nuclei  of  the  muscle-cells  as  well 
as  the  substance  proper.  Within  recent  years  it  has  been  shown  that  a  glyco- 
genesis  occurs  at  the  same  time  as  fatty  transformation  (Fig.  913). 

(3)  Vessels. — Involution  of  the  larger  vessels  is  accomplished  by  prolifera- 
tion of  the  intima  occurring  side  by  side  with  fatty  de- 
generation of  the  media.  The  capillaries  appear  to  be 
destroyed  outright  by  compression,  passing  rapidly  into 
a  state  of  fatty  degeneration.  The  nutrition  of  the 
uterus  is  maintained  by  the  partially  obliterated  vascular 
trunks. 

(4)  Decidua. — When  the  membranes  are  cast  off 
at  the  completion  of  delivery,  the  separation  occurs  at 
the  so-called  ampullary  layer  of  the  decidua.  This 
leaves  a  thin  stratum  of  decidual  tissue  which  serves  as 
a  temporary  lining  for  the  uterus  (Fig.  914).  At  the 
serotinal  portion  the  surface  is  more  or  less  bloody. 
The  remainder  of  the  lining  is  raw,  shreddy,  and  uneven 
through  the  forcible  separation  of  the  dilated  uterine 
glands.  Portions  of  the  decidual  layers  which  are  nor- 
mally cast  off  at  birth  may  remain  to  undergo  gradual 
necrosis  and  expulsion  with  the  lochia  (Figs.  907  to 
909).  The  persistent  portion  of  the  decidual  tissues 
undergoes  transformation  into  connective-tissue  corpus- 
cles, thereby  laying  bare  the  original  mucous  membrane 
of  the  uterus,  from  the  epithelial  cells  of  which  a  new 
mucosa  is  generated.  The  epithelium  in  this  case  comes 
from  the  uterine  glands  and  rapidly  proceeds  to  cover 
the  bare  septa  between  them.  This  process  of  repair  is 
always  accompanied  by  an  abundant  exudation  and 
leucocytosis.  According  to  some  authorities,  the  per- 
sistent decidual  cells  become  transformed  into  epithe- 
lium. 

(5)  Placental  Site. — This  portion  of  the  inner 
surface  of  the  uterus  necessarily  undergoes  a  reduction 
in    size    corresponding    to    that    of    the    uterus    itself. 

The  open  sinuses  are  at  first  protected  by  firmly  adherent  clotted  blood  and 
the  majority  become  occluded  by  thrombosis,  the  remainder  by  muscular 
compression.  The  placental  site  is  still  recognizable  for  from  four  to  six  weeks 
after  delivery  and  is  indicated  by  a  prominence  f  to  -f-  inches  in  width  (i  to 
2  cm.),  the  former  blood-vessels  persisting  only  as  pigmented  points.  It  thus 
appears  that  the  placental  site  is  the  last  portion  of  the  uterus  to  undergo 
complete  involution. 

(6)  Adnexa.— The  ovaries,  enlarged  during  pregnancy,  gradually  resume 
their  original  dimensions;  the  dilated  and  stretched  tubes  become  narrow 
and  tortuous;  the  peritoneal  coat  of  the  uterus  contracts,  and  the  laminae 
of  the  broad  ligament  become  unfolded  and  once  more  approach  each  other. 


Fig.  913.  —  Muscle-fi- 
bers OF  THE  Uterus 
ON  THE  Sixth,  Tenth, 
AND  Eighteenth 
Days  of  the  Puer- 
perium. 


LOCAL  PHENOMENA. 


683 


Changes  in  the  Breast  and  Milk  Secretion. — The  changes  m  the  breast  up 
to  the  time  of  the  puerperium  have  already  been  described.  During  the  first 
three  days  of  this  period  the  so-called  colostrum,  an  immature  milk,  is  secreted. 
This  is  a  turbid,  watery  fluid  which  exhibits  whitish  or  yellowish  streaks.  The 
microscope  shows  that  colostrum  is  an  irregular  emulsion,  its  fat-drops  being  of 
unequal  size  and  adhering  to  one  another  (Fig.  917).  This  point  serves  to  dis- 
tinguish between  this  fluid  and  milk,  the  latter  bemg  a  perfect  emulsion  (Fig. 
916).  Agglomeration  of  the  fluid  fat-drops  into  compact  masses  constitutes 
the  so-called  colostram  corpuscles.  It  is  probable,  however,  that  the  latter 
really    represent    a    complete 

fatty  degeneration  of  the  epi-  r       i  4  2    ■;    3 

thelium  of  the  mammary  gland. 
Colostrum  is  poor  in  casein  and 
rich  in  serum-albumin;  there- 
fore, unlike  milk,  coagulates  on 
boiling.  The  secretion  of  the 
breast  loses  its  coagulability  at 
the  latest  by  the  fourth  day, 
showing  the  period  of  transi- 
tion from  colostrum  to  milk. 
The  amount  of  breast  secretion 
during  the  colostrum  period  is 
relatively  insignificant.  After 
its  transition  into  milk  the 
amount  rapidly  increases. 
From  the  third  puerperal  day 
the  breasts  increase  rapidly  in 
size  and  usually  exhibit  fulness 
and  tension.  Individual  lobuli 
may  often  be  felt,  giving  the 
gland  a  nodular  character  (Fig. 
918).  '  The  swelling  about  the 
gland  proper  may  even  extend 
to  the  axilla,  and  may  be  ac- 
companied by  more  or  less 
pain.  That  a  milk  stagnation 
or  milk  fever  ever  occurs  as  a 
physiological  phenomenon  is 
now  disputed;  all  evidence  of 
this  sort  will  doubtless,  in 
time,  come  to  be  regarded  as 
due  to  bacterial  infection.  (See 
Fever,  Part  X.)     The  period  of 

active  congestion  which  ushers  in  the  secretion  of  milk  proper  does  not  last 
over  two  days  when  the  woman  nurses  her  child,  and  somewhat  longer  when 
she  does  not.  In  the  latter  case,  when  there  is  no  demand  for  its  secretion 
the  milk  gradually  assumes  the  character  of  the  original  colostrum,  and 
finally  disappears  altogether.  The  emptying  of  the  breast  in  lactation  is 
brought  about  as  follows :  The  infant  first  causes  an  erection  of  the  nipple  so 
that  the  first  milk  that  enters  the  sinuses  of  the  excretory  duct  is  abstracted 
by  the  pressure  and  suction  of  its  lips.  The  vis  a  iergo  is  then  brought  into 
play  through  reflex  stimulation  of  the  gland  by  the  act  of  suction,  so  that  an 


v^t\';0/'fa!'(«l»    f'fy      V.!i 


^M 


j    ^^ 


Fig.  914. — Regenerating  Mucous  Membrane  of 
THE  Uterus  on  the  Sixth  Day  of  the  Puer- 
perium. I,  Portion  of  necrosed  decidua  with  leu- 
cocytes free  and  embedded;  2,  edge  of  firm  decidua; 
3,  beginning  formation  of  new  epithelium;  4,  glands 
lined  with  epithelium ;  5 ,  wall  of  granulation  tissue 
under  the  necrosed  decidua;  6,  gland;  7,  capillary 
blood-vessels;  8,  disintegrating  and  degenerating 
decidual  cells  in  a  network  of  connective  tissue; 
9,  muscle  of  the  uterus;  10,  deepest  portion  of  the 
decidua  containing  spindle-shaped  cells. — (Bnmm.) 


684 


PHYSIOLOGICAL  PUERPERIUM. 


increase  occurs  in  the  secretory  pressure.  In  a  few  moments  after  the  appli- 
cation of  the  child  a  pain  is  felt  in  the  breast  and  the  milk  is  then  seen  to 
jet  forth.  This  may  often  be  observed  simultaneously  in  the  opposite  breast, 
and  even  in  both  glands  quite  independently  of  the  act  of  suction,  from  the 
mere  thought  of  suction. 

Human  milk  proper  is  a  white,  opaque  fluid  with  an  alkaline  reaction,  sweetish 
taste,  and  density  of  1030.     The  microscope  shows  it  to  be  composed  of  an 

emulsion  of  fat-drops  in  a  fluid  known  as 
the  milk  plasma  (Fig.  916).  These  fat- 
drops  rise  after  the  milk  has  stood  for  a 
few  hours  and  compose  the  cream.  During 
the  first  eight  days  of  the  puerperium,  or 
up  to  the  fourth  or  fifth  day  of  actual 
secretion  of  milk,  extraneous  formed  ele- 
ments may  be  recognized  by  the  micro- 
scope— blood-corpuscles,  fibrin,  colostrum 
corpuscles,  etc.  The  fat-drops  of  the  milk 
are  composed  of  a  number  of  fatty  acids 
(palmitic,  stearic,  oleic,  myronic,  butyric, 
etc.)  in  combination  with  the  glycerin 
radical,  thereby  forming  triglycerides  or 
neutral  fats  of  the  same  class  as  those 
which  make  up  adipose  tissue  of  animals 
in  general.  The  most  important  soluble 
ingredient  of  milk  is  the  proteid  matter, 
which  appears  to  undergo  considerable  fluc- 
tuation m  quality,  ^  that  a  given  test  does 
not  always  respond  in  the  same  fashion. 
It  is  admitted  that  the  principal  proteid 
constituent  is  casein,  and  some  chemists 
regard  it  as  the  sole  proteid  of  milk. 
The  majority,  however,  regard  serum-albu- 
min and  nuclein  as  normal  proteid  ingre- 
dients. The  existence  of  an  albuminoid 
envelope  about  the  fat-drops,  so  long  main- 
tained undisputed,  is  to-day  denied.  Hei- 
denhain  claims  that  the  mere  colloidal  ac- 
tion of  the  casein  in  solution  suffices  to  pre- 
vent the  coalescence  of  the  fat-drops.  The 
casein  is  combined  in  the  milk  with  calcium 
phosphate,  which  holds  it  in  solution.  If 
this  salt  is  withdrawn  from  the  combination 
by  the  addition  of  a  few  drops  of  a  weak 
solution  of  hydrochloric  or  acetic  acid,  the 
casein  is  immediately  precipitated.  Spon- 
taneous coagulation  is  due  to  the  action 
of  the  Bacillus  acidi  lactici,  which  forms  lactic  acid  from  the  lactose  of  the  milk 
and  thereby  precipitates  the  casein.  This  separates  the  milk  into  a  soHd  and 
a  fluid  portion  known  respectively  as  the  curd  and  whey.  Milk  which  curdles 
spontaneously  is  made  sour  through  the  formation  of  lactic  acid.  The  action 
of  rennet  or  lab  ferment  coagulates  the  milk  without  souring  it.  In  human 
milk    casein    is    always    precipitated    in    small    flocculi.     In    addition    to    the 


Fig.  915. — Section  through  an  Inac- 
tive Breast  at  the  Third  Week 
OF  the  Puerperium.  i,  Skin;  2, 
adipose  tissue;  3,  tubercles  of  Mont- 
gomery; 4,  nipple;  5,  milk  duct;  6, 
muscle;  7,  glandular  tissue;  8,  milk 
ducts;  9,  muscle. — {Bumm.) 


LOCAL  PHENOMENA. 


685 


proteid  matter,  milk  contains  milk-sugar  (lactose),  salts,  and  traces  of  a 
diastatic  ferment.  The  amount  of  milk  secretion  is  capable  of  increase  up 
to  the  eighth  month,  after  which  it  gradually  declines.  The  daily  average 
for  the  first  week  is  about  a  pint  (500  c.c),  which  gradually  increases  till  at 
its  maximum  it  is  over  a  quart  (i.i  liters).  As  a  general  rule,  lactation  is  com- 
pleted at  the  end  of  a  year,  but  this  period  is  subject  to  many  variations.  A 
secretion  of  milk  out  of  all  proportion  to  the  demands  of  the  child  is  known 
as  polygalactia,  and  if  it  persists  when  the  child  is  not  nursing  it  is  termed 
galactorrhea  (see  Part  VII).  Defective  secretion  of  milk  is  common  in  the 
very  young  or  the  elderly,  in  the  delicate,  weak,  and  cachectic.  The  obese  also 
suffer  in  this  respect,  the  breasts  in  such  women  being  subdeveloped.  According 
to  Baumm  and  Illner,  there  are  no  true  galactogogues,  nor  can  the  secretion 
of  milk  be  modified  by  the  diet;  but  the  amount  of  milk  can  be  much  lessened 
by  insufficient  diet  and  then  brought  to  the  normal  by  generous  regimen.  The 
composition  of  milk  varies  more  or  less  in  the  same  woman,  and  while  the 
gross  amount  is  not  affected  by  diet,  the  milk  may  be  made  richer  in  fat  by 


Pig.  916. — Contents  of  Milk,  i,  Fat- 
globules  (milk  corpuscles);  2,  milk  cor- 
puscles with  the  remains  of  the  proto- 
plasm of  the  gland  epithelium;  3,  milk 
corpuscles  covered  with  nucleated  pro- 
toplasm.— (Bumm.) 


Fig.  917. — Contents  of  Colostrum,  i, 
Fat-globules  of  different  sizes;  2,  epi- 
thelium of  the  milk  ducts;  3,  colostrum 
corpuscles.  (Leucocytes  containing  fat- 
corpuscles.) — (Bumm.) 


generous  living.  The  limits  of  variability  appear  to  be  as  follows:  Proteids, 
1.41  to  3.50  (per  cent.);  fat,.  1.42  to  5.25;  sugar,  5.04  to  7.76;  ash,  0.16  to 
0.36.  The  milk  of  a  primipara  is  somewhat  richer  in  solids  than  is  that  of  a 
multipara.  Age  alone,  within  certain  limits,  is  without  effect  upon  the  com- 
position of  the  milk.  The  period  of  lactation  exerts  ver}'  little  influence,  al- 
though during  the  first  ten  days  of  the  puerperium  there  is  a  steady  decline 
in  the  proteid,  which  thereafter  remains  constant.  Baumm  and  Illner  have 
made  many  studies  in  connection  with  feeding  nursing  mothers.  The  milk 
as  a  whole,  when  in  normal  quantity,  cannot  be  increased  by  feeding,  although 
individual  constituents  may  be  thus  affected.  Thus,  forced  feeding  with 
proteids  or  fats  increases  the  percentage  of  fatty  matter.  Carbohydrates 
have  no  effect  whatever.  Increased  ingestion  of  fluids  is  practically  without 
effect.  Illness  of  the  nursing  woman  does  no  more  than  diminish  slightly 
the  solid  constituents.  Neither  menstruation  nor  mental  emotion  has  any 
notable  effect  on  the  milk.  To  sum  up,  we  can  maintain  only  one  prominent 
truth  in  this  connection:  viz.,  that  the  richness  of  the  milk — or,  in  other  words, 


686 


PHYSIOLOGICAL  PUERPERIUM. 


the  proportion  of  fat — can  be  modified  in  various  ways.  The  following  are 
some  of  the  medicaments  which,  administered  to  the  mother,  may  enter  the 
milk:  Certain  coloring-matters,  ethereal  oils  (wormwood,  garlic,  etc.),  salicylic 
acid,  potassium  iodide,  the  heavy  metals  (lead,  mercury,  iron,  bismuth),  arsenic, 
antimony,  atropin,  chloral.  Narcotics,  including  alcohol,  while  having  a 
tendency  to  enter  the  milk,  do  so  in  such  small  quantities  that  the  infant  is 
not  menaced.  Human  milk  is  practically  sterile  when  secreted,  but  can  readily 
be  contaminated  with  staphylococci  from  the  milk-ducts  and  nipple.  In 
estimating  the  amount  of  milk,  the  usual  methods  of  palpating  the  breasts 
and  noting  the  force  with  which  the  milk  spurts  from  the  nipple  are  more  or 


Fig.  918. — Section  through  an  Inactive  Breast  during  the  Puerperium.  The  epi- 
thelium of  the  acini  shows  various  conditions.  i,  Quiescent  acinus ;_  2,  acinus  dis- 
tended with  milk;  3,  4,  5,  secreting  acini ;  6,  interacinous  connective  tissue;  7,  capil- 
laries; 8,  secreting  gland  epithehum  with  large  fat-corpuscles  in  the  protoplasm,  the 
nuclei  being  pressed  against  the  cell-wall;   9,  formed  milk. — (Bumm.) 


less  sources  of  fallacy.  A  more  sensible  way  of  arriving  at  this  knowledge 
is  by  the  examination  of  the  infant.  By  means  of  a  proper  scale  the  child 
may  be  weighed  before  and  after  each  feeding.  It  should  nurse  from  1.8  to 
7.2  ounces  (50  to  200  gm.)  according  to  age  every  two  hours.  Direct  analysis 
of  the  milk  is  required  only  for  the  determination  of  the  percentage  of  fat. 
High  specific  gravity  means  low  percentage  of  fat.  and  vice  versa.  The  micro- 
scope also  gives  information  of  some  value  in  this  direction,  as  does  allowing 
the  milk  to  stand  twenty-four  hours  and  computing  the  thickness  of  the  super- 
natant cream,  which  should  be  10  per  cent,  of  the  whole.  For  quantitative 
work  the  lactobutyrometer  will  give  approximate  results  to  the  practitioner. 
Subsequent  Impregnation. — How  soon  after  delivery  can  a  woman   again 


DIAGNOSIS  OF   THE  PUERPERIUM.  687 

be  impregnated?  G.  L.  Bonnar  *  reached  some  interesting  conclusions  in 
regard  to  this  question.  Not  being  satisfied  with  the  then  generally  accepted 
opinion  that  a  month  must  elapse  between  the  termination  of  labor  and 
a  fresh  conception,  he  undertook  an  investigation  into  what  was  known  as 
"Hodge's  Peerage  and  Baronetage."  His  results  were  as  follows:  In  at  least 
nineteen  cases  the  interval  between  one  birth  and  another  was  less  than  309 
days.  In  ten  cases  the  interval  varied  from  309  to  300  days,  in  two  from 
299  to  290,  in  four  from  289  to  280,  in  one  it  was  273,  in  another  252,  in 
another  182,  in  another  173,  and  in  one  127  days.  Taking  these  cases  into 
consideration,  as  well  as  the  post-partum  conditions  of  the  uterus,  lochia, 
and  vagina.  Dr.  Bonnar  placed  the  earliest  date  after  confinement  when  the 
woman  could  again  become  pregnant  as  the  fourteenth  day.  Leopold's  ob- 
servations appear  to  prove  that  the  repair  of  the  uterine  mucous  membrane 
after  confinement  is  not  complete  earlier  than  the  end  of  the  fourth  week; 
that  the  red  and  yellow  lochia  cease  at  the  beginning  of  the  second  week,  and 
that  the  white  lochia  continues  until  the  sixth  week.  Observations  would 
tend  to  indicate  that  one-half  of  those  women  who  do  not  nurse  their  children, 
and  also  those  women  who  menstruate  during  the  period  of  lactation,  have 
their  first  post-partum  menstrual  period,  and  hence  ovulation  and  capability 
of  impregnation,  within  six  weeks  after  confinement. 


III.  DIAGNOSIS  OF  THE  PUERPERIUM. 

I.  Signs  of  Recent  Delivery. — As  the  physician  is  required  to  render  a  decision 
not  only  in  the  case  of  the  living,  but  also  in  the  dead,  he  must,  from  signs 
present,  state  whether  or  not  a  recent  expulsion  of  the  contents  of  a  pregnant 
uterus  has  taken  place.  In  the  first  instance,  the  case  of  the  living,  the  decision 
is  reached  by  the  usual  methods  of  diagnosis ;  in  the  case  of  the  dead,  the  value 
of  an  inspection  of  the  uterus  and  its  appendages  is  added. 

(i)  Signs  in  the  Living. — As  in  the  diagnosis  of  pregnancy,  so  in  the  deter- 
mination of  the  existence  of  a  recent  delivery  in  the  living,  there  are  a  large 
number  of  signs  of  greater  or  less  value.  Doubtful  signs:  The  uncertain  symp- 
toms prove  nothing;  they  can  exist  in  conditions  other  than  that  of  the  puer- 
perium,  and  in  the  male  as  well  as  in  the  female.  Probable  signs:  These  include 
signs  existing  in -the  genital  tract  and  in  the  mammary  glands.  (See  Local 
Phenomena  of  Puerperium.)  Positive  signs.  Positive  proof  of  the  occurrence 
of  birth  is  furnished  only  by  the  discovery  of  parts  of  the  ovum.  If,  upon  careful 
microscopic  investigation  of  the  lochial  discharges  (see  Figs,  907,  908,  and  909) 
we  fail  to  find  any  evidence  of  remains  of  the  ovum,  we  can  with  the  finger  or 
curette  remove  the  remains  of  the  placenta  from  the  inner  surface  of  the  uterus, 
and  demonstrate  under  the  microscope  the  tissue  found,  thus  fully  establishing 
the  diagnosis.  The  demonstration  of  the  shreds  of  decidua  with  large  nucleated 
and  fatty  cells  is  of  itself  a  sure  proof.  The  diagnosis  of  the  puerperal  condition 
will  rarely  be  found  difficult  within  ten  or  fourteen  days  after  parturition.  In 
multiparas  the  diagnosis  cannot  in  some  instances  be  positively  established  after 
the  lapse  of  even  a  week  or  ten  days.  If  the  case  is  one  of  a  primipara,  the 
character,  intensity,  and  persistence  of  the  signs  present  will  permit  a  diagnosis 
to  be  made  at  a  later  date. 

Date  of   Delivery. — We  are   enabled   to   answer  this   question  by   carefully 

*  "  Critical  Inquiry  Regarding  Superfoetation,  with  Cases." 


688  PHYSIOLOGICAL  PUERPERIUM. 

observing  the  character  of  the  secretion  from  the  breasts;  the  appearance  and 
composition  of  the  lochial  discharge;  the  height  of  the  fundus  uteri  in  the  ab- 
dominal or  pelvic  cavity;  and  particularly  the  freshness  of  the  wounds  that  may 
exist  in  the  genital  tract. 

(2)  Signs  in  the  Dead. — The  diagnosis  of  recent  delivery  in  the  dead  rarely 
presents  any  difficulty.  Many,  if  not  all,  of  the  signs  of  recent  delivery  occurring 
in  the  living  may  be  found  in  the  dead,  and,  in  addition,  we  are  able  to  see 
the  alterations  in  the  uterine  body  and  its  appendages.  The  rate  of  return  of 
the  uterus  to  its  normal  size  depends  upon  so  many  factors — as  the  period  of 
gestation  at  which  labor  occurs,  pathological  conditions  in  the  pelvis  prior  or 
subsequent  to  labor,  the  general  condition  of  the  woman,  etc. — that  any 
attempt  to  state  positively  from  a  post-mortem  examination  the  exact 
date  upon  which  parturition  took  place  must  result  in  failure.  Four  to  six 
weeks  after  labor  the  placental  site  may  still  be  recognized,  but  it  is  smooth 
and  barely  two-thirds  of  an  inch  across,  and  the  places  formerly  occupied  by 
the  vessels  are  now  marked  by  yellow  and  black  spots  of  pigmentation.  As  to 
the  signs  of  pregnancy  revealed  by  a  post-mortem  examination,  those  of  an  objec- 
tive character  will  in  most  cases  be  present.  There  are  two  which  have  not  yet 
been  mentioned:  namely,  (i)  The  finding  of  the  ovum,  embryo,  or  fetus  within 
its  envelopes  in  the  uterus.  The  gross  appearance  of  the  ovum,  embryo,  and  fetus 
in  the  several  months  of  gestation  will  be  found  described  on  pages  82  and  83 ,  and, 
of  course,  this  furnishes  reliable  evidence.  (2)  The  presence  in  one  or  both  ovaries 
of  a  true  corpus  luteum.  After  the  Graafian  follicle  or  ovisac  ruptures  and  dis- 
charges the  ovum,  a  certain  change  takes  place  in  the  ruptured  follicle  which 
results  in  the  formation  of  the  corpus  luteum  (page  19).  Modern  investigation 
would  seem  to  sustain  the  statement  that  no  positive  evidence  is  to  be  derived 
from  either  the  false  or  the  true  corpora  lutea.  Instances  are  on  record  in  which 
the  so-called  true  corpus  luteum  has  existed  in  the  absence  of  pregnancy. 

2.  Primipara  and  Multipara. — In  primiparas  we  find  the  fragments  of  the 
freshly  torn  hymen,  fourchette,  and  possibly  permeum.  The  external  genitals 
are  usually,  also,  more  swollen,  reddened,  and  sensitive  to  the  touch  than  in 
multiparas. 

3.  Feigned  Lying-in  State. — (See  Feigned  Delivery,  page  449.) 


IV.  THE  MANAGEMENT  OF  THE  PUERPERIUM.    MOTHER. 

latroduction. — The  borderland  between  the  physiological  and  pathological 
puerperium  is  not  sharply  defined.  The  parturient  suffers  from  slight  trauma- 
tisms almost  through  the  entire  genital  tract;  she  has  thrombi  in  the  uterus  at 
the  former  site  of  the  placenta,  and  the  birth  canal  is  hypertrophied  above  and 
unduly  relaxed  below.  Physiological  conditions  may  so  readily  become 
pathological  that  the  obstetrician  should  constantly  be  on  his  guard  until 
the  time  of  danger  has  passed  (see  page  673).  As  alread}^  stated  (Part  IV), 
the  physician  should  remain  with  the  patient  for  at  least  an  hour  after 
the  completion  of  the  third  stage  of  labor.  During  this  period,  which  is 
called  "the  physician's  hour,"  the  abdominal  binder  and  first  vulval  dressing  are 
applied  as  already  described  (page  496),  after  a  thorough  cleansing  of  the 
external  genitals  and  neighboring  parts  with  an  antiseptic  solution.  The 
draw-sheet  has,  of  course,  been  removed  and  all  soiled  clothing  and  bed- 
ding have  been  replaced  by  clean  material.      It  is  essential,  however,  that  during 


THE  MANAGEMENT  OF   THE  PUERPERIUM.    MOTHER.      689 

this  process  the  patient  be  disturbed  as  little  as  possible,  and  if  she  is  much 
exhausted  she  should  be  allowed  to  rest  for  a  short  time  before  anything  is  done. 
The  head  should  be  kept  low  and  the  patient  not  allowed  to  turn  on  the  side, 
since  she  might  assume  the  Sims  position,  which  favors  the  entrance  of  air  into 
the  uterine  sinuses  and  possibly  air  embolism.  The  management  of  the  puer- 
perium  consists  chiefly  in:  (i)  cleanlmess  and  (2)  rest.  In  regard  to  cleanliness 
the  woman  should  be  aseptic  when  she  enters  the  lying-in  bed;  and  after  labor 
she  should  be  kept  as  aseptic  as  possible.  In  regard  to  asepsis  before  labor, 
it  is  taken  for  granted  that  the  pregnant  woman  has  formed  the  daily  habit  of 
general  bathing,  cleansing  the  mouth,  and  external  genitals. 

I.  Asepsis  during  the  Puerperium. — In  ordinary  cases  the  resources  of  nature 
cannot  be  equaled  by  those  of  art.  I  have  noted  the  importance  of  limiting  vaginal 
examinations  as  much  as  possible  in  the  first  and  second  stages,  and  the  danger  of 
unnecessary  manipulation  in  the  third  stage.  No  physician  is  competent  to 
manage  a  case  of  labor  who  cannot  in  the  great  majority  of  cases  so  conduct  the 
third  stage  that  no  internal  manipulations  are  necessary.     The  same  principles 


RETENTION  STRAP 


Fig.  919. — Abdominal  Binder  and  Breast  Support  for  the  Normal  Puerperium. 
The  retention  straps  connecting  the  lower  edge  of  the  binder  to  a  band  about  the  thighs 
are  used  only  when  the  binder  shows  a  tendency  to  slip  up  above  the  pelvis. — {From 
a  photograph^ 

of  treatment  should  guide  him  in  the  management  of  the  puerpermm.  Douches 
are  not  indicated  unless  unfavorable  symptoms  arise;  e.  g.,  high  temperature  or 
local  fetor.  (See  Treatment  of  Septic  Infection,  Part  VII.)  Cleanliness  of  the 
patient  and  bedding,  strict  antisepsis  of  the  external  genitals,  including  disin- 
fection of  lochia  and  thorough  ventilation  of  the  lying-in  room,  are  important 
points  to  be  remembered,  (i)  Antisepsis  of  the  external  genitals:  This  is  best 
secured  by  washing  with  sublimate  i  :  4000,  lysol  solution  (2  per  cent.),  and  pay- 
ing special  attention  to  the  flexures  of  the  thighs  or  any  folds  or  creases  of  skin 
which  may  serve  as  receptacles  for  septic  material.  The  lips  of  the  vulva  need  not 
be  separated ;  all  washing  should  be  done  from  above  downward  and  the  tissues 
about  the  anus  should  be  scrupulously  avoided  till  all  the  other  parts  are  cleansed. 
This  cleansing  of  the  external  genitals  should  precede  each  application  of  the 
vulval  dressing,  and  is  best  accomplished  by  vulval  irrigation  (Fig.  1055)  supple- 
mented with  sterile  cotton  wipes.  In  all  cases  internal  douches  or  other  internal 
manipulations,  especially  by  the  nurse  or  others,  in  the  absence  of  a  distinct 
indication,  are  to  be  absolutely  forbidden.  There  are  alwavs  some  abrasions 
44 


690  PHYSIOLOGICAL  PUERPERIUM. 

and  small  wounds  in  the  genitals  which  if  not  treated  antiseptically  may  become 
the  starting-point  of  an  infection;  it  is  therefore  necessary  to  conduct  the  vulval 
dressing  with  strict  attention  to  these  details.  (2)  The  vulval  dressing:  There 
are  three  essentials  of  a  vulval  dressing:  (a)  It  should  be  of  absorbent  material, 
that  the  accumulation  of  lochia!  discharge  about  the  vulva  may  be  prevented; 
(6)  it  should  be  saturated  with  an  antiseptic  material  that  the  discharge  may 
be  sterilized;  (c)  it  should  be  impermeable,  that  the  air  may  be  excluded.  As 
an  absorbent,  gauze  or  cotton  may  be  used,  and  should  be  borated  or  salicylated; 
sublimate  is  too  irritating  for  this  purpose.  Deodorizing  chemicals,  or  those 
with  any  odor,  should  not  be  used  on  the  vulval  dressing,  as  these  mask  the 
fetor  of  decomposing  lochia,  a  valuable  sign  of  early  septic  infection.  Over  the 
vulval  dressing  a  long  strip  of  salicylated  cotton  wrapped  in  gauze  should  be 
placed  and  attached  in  front  and  behind  to  the  abdominal  binder.  The  vulval 
dressing  should  be  changed  every  four  to  six  hours.  While  the  foregoing  pre- 
cautions cannot  be  carried  out  in  every  case,  it  is  fortunately  true  that  if  the 
vaginal  examinations  in  the  first  two  stages  of  labor  are  made  with  great 
care  as  to  asepsis  and  limited  as  to  number,  if  internal  manipulations  are  care- 
fully avoided  during  the  third  stage,  and  if  strict  cleanliness  of  the  patient  and 
bedding  is  observed,  very  good  results  can  be  obtained  even  in  the  most  un- 
favorable surroundings. 

2.  Rest. — The  first  and  most  important  requisite  is  that  the  patient  should 
have  a  period  of  refreshing  sleep.  She  may  be  allowed  to  see  her  husband  or 
mother  for  a  short  time  if  she  desires,  but  all  other  visitors  should  be  rigidly 
excluded.  She  should  not  be  disturbed  by  the  congratulations  of  friends 
nor  the  intrusions  of  the  curious,  and  if  it  is  impossible  to  exclude  them  she 
should  not,  know  of  their  presence  in  the  house,  nor  should  she  be  disturbed  by 
the  crying  of  the  baby.  The  room  should  be  darkened  and  perfect  qtiict  ob- 
served. It  cannot  be  too  often  repeated  that  perfect  cleanliness  and  absolute 
physical  and  mental  rest  shotdd  usher  in  the  puerperium.  The  nurse,  however, 
should  from  time  to  time  note  the  pulse  and  general  aspect  of  the  patient,  and 
the  presence  of  uterine  contractions.  The  exclusion  of  visitors  and  the  ob- 
servance of  quiet  should  not  be  limited  to  the  first  day  or  few  days,  but  should 
continue  at  least  as  long  as  the  patient  is  confined  to  her  bed. 

3.  Special  Directions. — The  patient  should  be  seen  again  within  twelve 
hours  after  delivery,  or  sooner  if  required  by  the  frequency  of  the  pulse,  rise  of 
temperature,  excessive  flowing,  or  any  other  unfavorable  symptoms.  Morning 
and  evening  visits  may  be  made  for  the  first  two  or  three  days,  and  daily  visits 
till  the  tenth  day  or  later,  the  patient  being  kept  under  observation  till  involu- 
tion is  complete.  At  each  visit  attention  should  be  paid  to  (i)  the  mother's  tem- 
perature, pulse,  and  respiration  (a.m.  and  p.m.);  (2)  the  height  and  condition 
of  the  uterus;  after-pains;  (3)  the  quantity,  odor,  and  character  of  the  lochia; 
(4)  the  condition  of  the  external  genitals;  (5)  the  condition  of  the  bladder; 
(6)  the  condition  of  the  bowels;  (7)  the  condition  and  secretion  of  the  breasts;  (8) 
the  nipples;  (9)  diet;  and  (10)  the  general  condition  of  the  patient  and  the  neces- 
sary treatment  if  any  is  required.  Note  should  also  be  taken  of  (i)  the  child's 
temperature,  pulse,  and  respiration,  but  it  is  unusual  to  take  the  infant's  rectal 
temperature  except  for  special  indications;  (2)  the  condition  of  the  stump  of  the 
cord  and  the  umbilicus;  (3)  the  number  and  color  of  the  stools;  (4)  the  passage 
of  urine;  (5)  the  color  and  condition  of  the  skin;  (6)  the  condition  of  the  eyes 
(inflammation);  (7)  maternal  nursing  or  artificial  diet;  (8)  the  stomach  as  shown 
by  vomiting;  (9)  the  weight;  (10)  the  condition  of  the  nose  and  mouth;  (11)  the 
general  condition  as  to  sleep,  excessive  crying,  colic,  irritation.   For  the  care  of  the 


THE  MANAGEMENT  OF  THE  PUERPERIUM.      MOTHER.        691 

newly  bom  infant,  see  Part  VIII.     (i)   Temperature,  pulse,  resptration:  A  diurnal 
record  should  be  made  of  the  temperature  and  pulse,  and  when  the  latter  is  taken 
by  the  attending  physician  it  is  advisable  to  note  its  rapidity  both  at  the  begin- 
ning and  at  the  end  of  his  visit.     Any  departures  from  the  normal  standard  should 
call    for   rigid    investigation   into    the   cause.      (See  Part  VIII.)     These  three 
conditions    should    all    return    to    normal    on    the    second    day.       The    pulse 
is  accelerated  during  and  immediately  after  delivery  and  the  temperature  may 
show  a  moderate  rise  during  the  first  thirty-six  hours,  but  after  that  any  elevation 
of  temperature  should  be  regarded  with  suspicion  (Part  VIII).     (2)   The  height 
and  condition  of  the  uterus:  The  height  of  the  uterus  above  the  symphysis  should 
be  estimated  or  measured;  and  the  sensitiveness  and  contractility  determined 
by  abdominal  palpation,  not  neglecting  at  the  same  time  to  search  for  evidences 
of  perimetritis  or  parametritis  by  palpating  over  the  adnexa  and  in  the  iliac 
fossae.     After-pains:  These  are  caused  by  irregular  and  painftd  uterine  contrac- 
tions, and  are  often  due  to  clots  in  utero.     The  use  of  the  fluid  extract  of  ergot, 
one  drachm  every  three  hours,  is  usually  beneficial  in  cases  of  retained  blood- 
clots.     Should   the  sleep   be  much   disturbed,  codein  in  moderate  doses,  one- 
quarter  grain  every  two  hours  for  two  or  three  doses,  may  be  used  as  less  likely 
to  produce  unpleasant  after-effects  than  other  preparations  of  opium.     De- 
pressants should  be  avoided.     When  pain  is  moderate  and  not  due  to  blood- 
clots,  phenacetin,  five  grains  every  three  hours  for  two  or  three  doses,  will  be 
found  useful.     I  have  found  antipyrin,  five  grains,  with  a  teaspoonful  of  aromatic 
spirits  of  ammonia  every  hour  for  two  or  three  doses,  efficient.     When  the  pain 
is  severe  and  not  due  to  retained  clots,  the  following  will  answer  well:  Tincturae 
opii   deodoratae,   5i;   chloralis  hydratis,   gr.   xl;  elixiris   aromatici   q.  s.  ad   .^i. 
Sig. :  Teaspoonful  in  water  not  oftener  than  every  four  hours.     (3)  The  lochia: 
The  physician  should  not  neglect  to  inform  himself  as  to  the  amount  and  char- 
acter of  the  lochia.     Marked  diminution  or  suppression  or  the  presence  of  a 
putrid  odor  should  lead  to  the  suspicion  of  sepsis  and  a  careful  investigation. 
If  the  red  color  persists  much  longer  than  usual,  it  is  probably  due  to  subinvo- 
lution (page  708).     The  lochial  stain  in  healthy  cases  is  red  in  the  center,  gradu- 
ally fading  away  toward  the  periphery.     In  cases  of  putrid  lochia  the  circum- 
ference of  the  stain  is  well  marked,while  the  color  at  the  center  is  lighter.     Famil- 
iarity with  the  sometimes  heavy  but  not  offensive  odor  should  be  cultivated 
in  order  to  avoid  mistakes.     (4)  The  external  genitals:  Antisepsis  of  the  external 
genitals  has  already  been  referred  to  (page  689).      (5)  The  bladder:  A  frequent 
and  annoying  complication  of  the  puerperium  is  the  retention  of  urine,  of  which 
the  causes  have  been  noted  (page  676).     At  his  first  visit  the  physician  should 
satisfy  himself  by  percussion  and  palpation  as  to  the  condition  of  the  bladder. 
The  use  of  the  catheter  should  be  avoided  if  possible  and  urination  encouraged 
by  the  application  of  hot  cloths  to  the  abdomen  and  vulva,  by  small  doses  of 
ergot  and  the  sound  of  running  water,  by  tightening  the  binder  or  compressing 
the  abdomen  to  reinforce  the  action  of  the  lax  walls.     The  patient  may  succeed 
after  the  first  three  days,  by  the  cautious  assumption  of  the  sitting  posture. 
The  dangers  of  sitting  up  at  this  time  have  been  very  much  exaggerated,  and 
if  the  uterus  is  well  contracted  and  the  pulse  not  affected  by  the  position  it  is 
probably  preferable  to  the  passage  of  the  catheter.     It  should  be  remembered 
that  the  danger  of  cystitis  from  the  passage  of  the  catheter  is  decidedly  in- 
creased after  the  second  or  third  day  on  account  of  the  beginning  decomposition 
of  the  lochia.     As  a  rule,  the  patient  may  be  allowed  to  hold  water  for  twelve 
hours  if  the  uterus  is  well  contracted  and  there  is  no  danger  of  hemorrhage,  and 
she  should  be  encouraged  in  the  effort  to  avoid  the  catheter.     If  its  use  becomes 


692  PHYSIOLOGICAL  PUERPERIUM. 

inevitable,  it  shotdd  be  passed  with  all  aseptic  precautions.  The  external  genitals 
should  be  carefvdty  cleansed,  the  region  of  the  meatus  should  be  sponged  with 
a  I  :  4000  sublimate  solution,  and  the  catheter  inserted  under  the  guidance  of 
the  eye,  A  glass  catheter  should  be  used  when  possible,  as  it  admits  of  perfect 
sterilization  by  boiling.  It  is  a  useful  precaution  for  women  during  the  last  few 
weeks  of  pregnancy  to  become  accustomed  to  urinating  in  the  recumbent  posture. 
(6)  The  bowels:  A  laxative  shoiild  be  given  at  the  end  of  the  first  forty-eight 
hours.  Castor  oil,  from  one-half  to  one  ounce,  if  not  offensive,  is  preferable.  Com- 
pound licorice  powder  is  a  good  preparation.  When  the  patient  feels  an  incli- 
nation for  a  movement,  it  is  well  to  soften  the  rectal  contents  by  an  injection 
of  two  or  three  ounces  of  olive  oil  or  water,  since  owing  to  the  bruises  and  small 
lacerations  incident  to  labor,  the  passage  of  hard  fecal  masses  is  sometimes  very 
painful.  The  same  procedure  is  valuable  in  perineorrhaphy  cases  (Part  X).  A 
laxative  may  be  given  from  time  to  time  while  the  mother  remains  in  bed,  but 
if  enemata  are  sufficient  they  are  preferable.  Many  women  are  unable  com- 
pletely to  empty  the  bladder  or  bowel  by  the  use  of  the  bed-pan,  and  resulting 
pelvic  congestion  and  pressure  are  favored.  The  difficulty  could  have  been 
avoided  had  the  patient  been  trained  in  the  use  of  the  bed-pan  during  preg- 
nancy. Another  remedy  for  incomplete  bladder  or  bowel  evacuation,  and  a 
method  which  at  the  same  time  favors  uterine  drainage,  is  permitting  the  patient 
to  sit  upon  the  vessel  placed  in  the  bed  or  upon  a  commode  at  the  bedside,  early 
in  the  puerperiimi,  for  bladder  and  bowel  evacuation.  This  has  in  the  past  been 
recommended  by  some  in  selected  cases,  and  by  others  in  all.  In  my  observa- 
tion during  the  past  ten  years  on  many  thousands  of  cases  confined  in  the  tene- 
ments, I  have  never  seen  dangerous  symptoms  result  from  this  practice,  and 
yet  the  majority  of  patients  within  six  or  eight  hours  of  their  confinement  either 
sat  upon  a  vessel  in  bed  or  at  the  bedside  to  pass  urine.  (7  and  8)  The  breasts 
and  nipples:  The  management  of  the  nipples  during  the  latter  months  of  preg- 
nancy in  cases  of  deficient  development  has  been  mentioned  (page  187).  With 
the  establishment  of  the  milk  secretion  on  the  third  day  the  breasts  sometimes 
become  the  seat  of  painftil  distention,  owing  to  the  excessive  secretion,  and  the 
relief  afforded  by  putting  the  infant  to  the  breast  may  not  be  sufficient  to  relieve 
the  condition.  One  of  the  best  methods  to  correct  the  overdistention  is  massage 
and  milking  the  breasts  through  a  piece  of  hot  sterile  flannel,  the  milk  being 
allowed  to  flow  into  the  warm  flannel  (Part  VII)  (Fig.  967).  Breast-pumps  are 
to  be  avoided  if  possible,  but  if  used-the  action  should  be  assisted  by  the  nurse, 
who  should  gently  compress  the  breast  and  massage  it  with  the  finger-tips  from  the 
periphery  toward  the  nipple  (Figs.  967,  968,  969).  All  rough  handling  should  be 
avoided.  Uniform  compression  and  considerable  relief  may  be  afforded  by  the 
use  of  a  breast  bandage,  with  or  without  hot  stuping  (Fig.  972).  If  the  distention 
is  very  great,  it  may  be  advisable  to  administer  a  saline  cathartic  and  restrict  the 
supply  of  liquids,  milk  included,  for  a  time.  The  application  of  a  hot  lead  and 
opium  wash  may  afford  relief,  but  great  care  should  be  taken  when  applying  the 
child  to  the  breast.  Before  and  after  each  nursing  the  nipples  shotdd  be  care- 
fully cleansed  with  a  saturated  solution  of  boric  acid  and  covered  with  sterilized 
gauze  without  exercise  of  pressure.  It  is  a  useful  precaution  against  cracks  and 
fissures  of  the  nipple  to  anoint  the  nipple  and  tissues  about  its  base  with  steril- 
ized sweet  oil  after  each  nursing.  The  importance  to  both  mother  and  child  of 
the  proper  performance  of  the  fimction  of  lactation  is  universally  admitted. 
Its  favorable  influences  upon  uterine  contraction  and  involution  and  the  subse- 
quent prevention  of  uterine  disease  should  never  be  forgotten. 


THE  MANAGEMENT   OF   THE  PUERPERIUM,     MOTHER.      693 

If  the  child  is  still-born  or  dies  subsequent  to  labor  or  it  is  necessary  to  wean 
for  any  cause  the  proper  care  of  the  breasts  is  important. 

Of  the  various  treatments  proposed  for  controlling  and  drying  up  the  milk 
secretion,  I  have  been  most  successful  with  the  following: 

1.  The  application  of  a  tight  well-fitting  breast  binder,  after  the  breasts 
have  been  lightly  smeared  with  a  solution  of  atropin  sulphate  in  glycerin 
(gr.  i  to  Bj).     This  is  repeated  twice  in  the  twenty-four  hours. 

2.  The  cutting-down  of  the  liquid  intake  to  a  minimum. 

3.  The  causing  of  free  watery  stools  with  saline  cathartics. 

4.  The  avoidance  of  all  massage  of  the  breasts  or  the  use  of  breast-pumps 
if  possible. 

Should  the  breasts  become  very  hard  and  painful,  the  application  of  hot 
flannel  stupes,  and  the  massaging  out  of  the  milk  secretion  through  and  into 
the  stupes  is  permissible. 

In  the  case  of  still-born  children,  and  when  the  above  treatment  can  be 
instituted  before  the  fiUing-up  of  the  breasts  on  the  third  day,  stuping  and 
massage  are  rarely  necessary,  and  should  be  avoided  if  possible  in  any  case. 

4.  Diet. — Individual  characteristics  must  be  considered,  also  the  character  of 
the  delivery  and  whether  it  was  accompanied  with  little  or  great  loss  of  blood. 
A  mixed  diet  seems  to  give  the  best  results  and  may  be  begun  on  the  first  day. 
This  form  of  diet  causes  the  least  loss  of  weight.  During  the  first  few  days 
it  is  well  to  give  a  highly  albuminized  diet,  and  alcoholics  should  not  be  used 
except  in  the  presence  of  collapse  or  weakness.  Milk,  wheaten  and  other 
forms  of  bread,  soups,  and  well-cooked  meats  form  the  basis  of  the  diet.  Until 
the  bowels  have  moved  on  the  second  or  third  day  a  light  diet,  is  advisable. 
Milk,  milk-toast,  soup,  gruel,  or  clam-broth  may  be  given.  A  small  amount 
of  tea  may  be  allowed  if  the  patient  is  accustomed  to  its  use  and  desires  it. 
Coffee  is  apt  to  cause  insomnia.  After  the  bowels  have  moved,  the  appetite 
of  the  patient  may  be  trusted  as  a  safe  guide.  The  starvation  diet  is  obsolete. 
In  view  of  the  amount  of  disintegrated  tissue  to  be  eliminated,  it  would  seem 
that  an  excess  of  nitrogenous  food  is  not  indicated.  Articles  which  cause  con- 
stipation should  be  avoided.  If  the  breast  secretion  is  deficient,  however,  a 
liberal  quantity  of  milk  is  the  best  remedy. 

Diet-list  After  Normal  Confinement.     First  Day  or  Two. 

Liquids. — Milk,  hot  or  cold;  beef -tea,  weak  tea;  beef -broth  or  chicken-broth; 
beef -juice;  egg  shake;  clam-broth;  simple  soups  and  cocoa. 

Solids. — Thin  bread  and  butter;  saltine  or  soda  crackers;  milk-toast;  dr>''  or 
buttered  toast;  dropped  or  soft-boiled  eggs;  any  breakfast  cereal  thor- 
oughly cooked. 

After  First  Two  Days. — Liquids  as  above  with  addition  of  coffee.  Solids: 
Any  breakfast  cereal;  scrambled,  soft-boiled,  or  dropped  eggs;  broiled 
whitefish;  lamb  chop;  beefsteak;  roast  lamb;  broiled,  baked,  or  creamed 
chicken;  baked,  mashed,  or  stewed  potatoes;  macaroni;  celery;  lettuce; 
fruits;  fresh  vegetables,  such  as  peas,  asparagus,  and  string-beans  in  season 
and  in  moderation;  boiled  or  baked  custard;  curds  and  whey;  wine  jelly; 
simple  puddings,  such  as  rice,  tapioca.  Avoid:  Nursing  mothers  should 
avoid  whatever  previously  disagreed  with  them,  and  usually  also  pork, 
veal,  corned  beef,  cabbage,  turnips,  cucumbers,  com,  beans  (canned  and 
dried),  vinegar,  strawberries,  and  melons  unless  thoroughly  ripe. 

Sample  Breakfasts. — (i)  Any  breakfast  cereal;  soft  egg;  tea.  (2)  Orange;  cereal 
and  cream;  scrambled  egg;   tea  or  cocoa.     (3)  Cereal;  broiled  whitefish; 


694  PHYSIOLOGICAL  PUERPERIUM. 

bread  and  butter;  tea,  coffee,  or  cocoa.     (4)  Lamb  chop;  stewed  potatoes; 

toast;  tea,  coffee,  or  cocoa.     (5)  Orange;  scrambled  or  dropped  egg;  minced 

chicken;  graham  bread;  coffee. 
Sample  Dinners. — (i)  Broiled  or  roast  chicken;  sweet  potato;  baked  cup  custard. 

(2)  Roast  lamb;  mashed  potato;   macaroni;  wine  jelly.     (3)  Roast  beef; 

celery;  mashed  potato ;  rice  pudding.     (4)  Simple     soup;  chicken;  stewed 

potatoes;  baked  cup  custard.     (5)  Raw  oysters  with  any  of  the  above. 
Sample  Suppers. — (i)  Creamed  chicken  on  toast;  milk  or  cocoa.     (2)  Oyster 

stew;  bread  and  butter;  cocoa.     (3)  Minced  chicken  on  toast ;  baked  apples 

and  cream;  tea.     (4)  Dropped  eggs  on  toast;  graham  bread  and  butter; 

cocoa  or  tea.     (5)  Raw  oysters  with  any  of  the  above. 

5.  Posture  and  Duration  of  the  Puerperium. — For  the  first  few  hours  after 
labor  the  pillows  should  be  removed  and  the  head  kept  low  to  guard  against 
the  occurrence  of  cerebral  anemia.  For  a  day  or  two,  and  especially  when  the 
binder  is  not  in  place,  the  patient  should  on  no  account  be  allowed  to  turn 
on  her  side,  for  reasons  stated  (page  689).  For  the  first  two  or  three  days 
the  patient  should  remain  quiet,  lying  on  the  back,  which  position  is  most 
favorable  for  the  closing  of  the  uterine  sinuses,  the  healing  of  abraded  surfaces, 
and  escaping  lochia.  She  should  retain  the  recumbent  position  in  bed  until 
the  uterus  can  no  longer  be  felt  by  external  palpation;  that  is,  ten  days  or 
two  weeks.  The  practice  of  keeping  the  patient  on  her  back  for  all  of  this  period 
is  not  to  be  recommended.  It  is  unnatural  and  depressing,  and  tends  to  cause 
posterior  displacement  of  the  uterus,  sacculation,  and  interference  with  drainage. 
After  the  first  seventy-two  hours  the  patient  should  be  encouraged  to  turn 
first  on  one  side  and  then  on  the  other,  and  later  to  lie  on  the  abdomen,  and 
finally  to  sleep  in  this  position.  At  the  beginning  of  the  third  week  the  patient 
may  be  lifted  into  a  reclining  chair  or  on  a  sofa,  and  may  sit  up  for  a  short 
time  each  day  as  her  strength  permits.  After  the  fourth  week  she  may  go 
about  the  house  or  drive  in  the  open  air,  but  on  no  account  should  she  resume 
her  household  duties  or  do  any  lifting,  long  standing,  or  walking  until  the 
period  of  involution  is  complete.  The  physician  will  not  only  do  his  duty 
to  his  patient,  but  will  save  himself  subsequent  reproach,  by  insisting  on 
the  observance  of  these  rules,  and  he  will  find  that  every  intelligent  patient 
will  submit  willingly  to  restraint  or  inconvenience  if  he  explain  to  her  how 
largely  her  future  health  or  even  life  may  depend  on  care  and  moderation 
during  the  lying-in  period.  Getting  up  too  soon,  and  especially  too  early 
resumption  of  household  duties,  are  important  factors  in  the  production  of 
displacements  and  even  prolapse,  particularly  when  delivery  has  been  at- 
tended by  some  lesion  of  the  pelvic  floor  which  has  been  neglected  or  im- 
properly treated.  Patients  even  after  leaving  the  bed  shotdd  spend  part 
of  each  day  in  the  recumbent  posture,  and  the  occurrence  of  a  backache 
should  be  regarded  as  a  warning  against  standing  or  walking  and  against  any 
kind  of  work.  One  reason  why  the  puerperal  woman  is  better  for  a  considerable 
rest  in  bed  after  delivery,  and  why  the  same  kind  of  rest  is  not  necessary  in 
the  case  of  quadrupeds,  is  that  in  the  erect  posture  natural  to  human  beings 
the  uterus  and  its  appendages  and  the  floor  of  the  pelvis  are  subjected  to  a 
downward  pressure  which  does  not  occur  in  a  quadrupedal  position.  When 
the  woman  does  not  rest  recumbent  long  enough  after  deli\rery,  she  is  liable 
to  many  forms  of  uterine  displacement,  and  her  too  early  getting  up  may  cause 
hemorrhage  by  dislodging  clots  from  the  uterine  sinuses,  or  thrombosis  may 
occur  in  the  veins  of  the  broad  ligament  with  danger  of  embolism  in  the  heart 


THE  MANAGEMENT  OF   THE  PUERPERIUM.     MOTHER.       695 

or  lungs.  The  duration  of  the  rest  in  bed  is  variously  given  as  seven,  fourteen, 
to  twenty-one  days.  The  first  is  too  short  except  in  very  unusual  cases.  A 
rest  of  two  weeks  followed  by  gradual  resumption  of  ordinary  activities  is 
the  usual  period  required.  Involution  of  the  uterus  is  not  completed  for  a 
period  of  five  or  six  weeks,  but  if  a  patient  is  kept  in  bed  as  long  as  that  she 
loses  flesh  and  strength  and  her  appetite  fails.  When  the  patient  first  gets  up, 
she  should  remain  up  only  an  hour  or  so  in  the  day. 

6.  Prophylaxis  in  the  Puerperium. — While  we  cannot  be  so  aggressive  in 
our  methods  in  the  puerperium  as  in  labor,  yet  there  is  much  that  may  be 
accomplished  in  the  way  of  prophylaxis.     The  all-important  question  at    this 


Fig.    920. ^Pelvic    Binder   and    Pelvic  Fig.  921. — Pelvic  Binder  and  Perineal 

Floor   Support    for   Use    after   the  Support.     Posterior  View. 

Puerperium.* — (From  a  photograph.) 

time  is.  How  can  we  best  secure  involution  in  the  puerperal  state  ?  It  is  during 
the  puerperium  that  we  should  rivet  our  attention  on  the  prevention  of  sub- 
involution, especially  in  cases  following  the  premature  interruption  of  preg- 
nancy. Were  closer  attention  given  this  subject  in  practice,  the  sequelae 
of  subinvolution — metritis,  endometritis,  retrodisplacements,  and  prolapse 
— would  be  less  frequently  met  with. 

(i)  The  Abdominal  Binder. — The  proper  treatment  of  the  relaxed  ab- 
dominal walls  after  delivery  is  of  great  importance  for  cosmetic  reasons 
and  to    prevent  the   results  of  pendulous  abdomen.      A    certain    amount  of 

*  These  binders  may  be  obtained  from  the  Home  Bureau,  52  West  39th  Street,  New 
York  City. 


696 


PHYSIOLOGICAL  PUERPERIUM. 


fixation  is  necessary  for  proper  involution  of  the  abdominal  walls,  and  this  is 
best  secured  by  a  binder.  The  binder  tends  to  prevent  atony  and  lack  of  contrac- 
tion in  the  uterus,  splanchnoptosis  of  the  abdominal  viscera,  and  obviates  the 
danger  of  sudden  filHng  of  the  abdominal  veins  due  to  the  greatly  lessened  intra- 
abdominal pressure  after  confinement.  The  binder  when  properly  applied  con- 
duces to  the  patient's  comfort,  especially  by  permitting  her  to  assume  the  lateral 
position.  It  should  not  be  applied  too  tightly,  as  this,  combined  with  prolonged 
dorsal  decubitus,  tends  to  cause  posterior  displacement  of  the  uterus. 

(2)  The  Pelvic  Binder. — After  the  patient  begins  to  move  about,  the  ordi- 
nary abdominal  binder  is  with  difficulty  kept  in  place,  and,  moreover,  by  this 
time  has  pretty  much  served  its  purpose.  At  this  time  in  all  cases,  but  especially 
in  those  of  undue  pelvic-floor  projection,  and  in  patients  with  weak  and  over- 
distended  abdominal  walls  (twins,  hydramnios),  I  am  accustomed  to  replace  the 
abdominal  with  a  pelvic  binder,  to  sustain  the  pelvic  floor  and  the  antero-lateral 

abdominal  wall  for  three  months  following 
the  puerperium  (Figs.  920,  921,  and  922). 
The  binder  is  made  of  muslin,  linen,  mull, 
canton  flannel,  or  two  thicknesses  of  heavy 
gauze,  and,  as  the  illustrations  show,  is  made 
to  encircle  the  pelvis  and  lower  abdomen  at 
a  level  with  the  crests  of  the  ilia  and  to  sup- 
port the  pelvic  floor  by  a  strap  of  the  same 
material  passing  between  the  thighs,  and, 
tightly  drawn,  is  pinned  in  front  or  behind  as 
convenient.  Ordinary  corset  lacing  down  the 
front  or  back  secures  a  snug  fitting  to  the  bin- 
der. The  pelvic  binder,  when  applied,  laced, 
and  the  perineal  band  secured,  is  not  unlike 
in  appearance  and  shape  the  ordinary  swim- 
ming trunks  worn  by  bathers.  I  am  accus- 
tomed to  have  half  a  dozen  pelvic  binders 
fitted  and  made  in  the  latter  part  of  the 
puerperium  and  to  replace  the  use  of  the  ab- 
dominal binder  with  them  as  soon  as  the 
lochia  has  practically  ceased  in  the  third 
week,  when  the  patient  first  commences  to 
sit  up  in  bed  or  changes  from  bed  to  lounge, 
and  to  continue  its  use  for  three  months  from 
that  time.  The  results  obtained  by  the  use 
of  this  support  have  been  more  than  satisfactory.  It  is  appreciated  by  the  patients 
themselves,  some  having  used  them  after  four  confinements,  (i)  It  prevents  or 
corrects  undue  sagging  of  the  pelvic  floor.  This  is  especially  noticeable  in. cases 
in  which  during  labor  the  levator  ani  muscle  has  been  subjected  to  severe  or  pro- 
longed pressure,  severe  lacerations  with  bad  union,  and  in  which  the  levator  ani  is 
torn,  the  perineum  remaining  intact.  (2)  It  assists  in  the  ultimate  union  of  severe 
lacerations  of  the  pelvic  floor  which  have  been  repaired.  (3)  It  preserves  the 
woman's  figure  after  confinement  by  its  support  of  the  lower  anterior  abdominal 
wall  and  the  pelvic  floor.  (4)  It  lessens  the  danger  of  displacement  of  the  pelvic 
contents.  (5)  It  tends  to  prevent  pelvic  congestion.  (6)  It  usually  adds  to  the 
comfort  of  the  patient,  giving  her  a  feeling  of  security  and  well-being  and  allowing 
her  to  obtain  needed  exercise  earlier  and  more  freely  than  would  otherwise  be  the 
case.     Unless  preexisting  pelvic  disease  is  present,  with  the  use  of  this  pelvic  sup- 


VIEW. 


Fig.  922. — ^Pelvic  Binder  and  Peri- 
neal Support,  showing  Shape. 


THE  MANAGEMENT   OF   THE  PUERPERIUM.     MOTHER.       697 

port  we  rarely  see  the  danger  signals  of  pelvic  congestion— backache  and  irritable 
bladder;  and  the  complex  nervous  manifestations  of  splanchnoptosis  in  general 
and  of  gastroptosis,  nephroptosis,  and  enteroptosis  in  particular. 

(3)  Medication. — What  place  have  drugs  and  various  non-medicinal  methods 
of  treatment  of  the  puerperium  in  the  prevention  of  subinvolution  and  subse- 
quent gynecological  conditions?  During  the  past  ten  years  I  have  experimented 
with  various  methods  of  managing  the  puerperium  with  the  object  of  deter- 
mining, if  possible,  the  best  treatment  for  the  prevention  of  subinvolution 
and  subsequent  gynecological  conditions.  Ergot,  quinine,  repeated  hot  vaginal 
irrigations,  apparently  have  no  effect  in  hastening  uterine  involution.  The 
best  results  were  obtained  with   (i)   strychnin  administered  both  during  the 


Fig.  923. — Breast  Support  for  Nursing 
Women. — (From  a  photograph.) 


Fig.  924. — India  Gauze  Bodice  used  as 
Breast  Support. — {From  a  photograph.) 


latter  part  of  pregnancy  and  during  the  first  ten  days  of  the  puerperium;  (2) 
rotation  of  the  patient  as  regards  posture  during  the  lying-in  state;  (3)  early 
use  of  the  vessel  in  bed  or  the  commode  at  the  side  of  the  bed,  favoring  drainage 
and  avoiding  pelvic  congestion. 

(4)  Massage  and  Exercise. — Massage,  including  dry  friction  of  the  skin 
of  the  whole  body,  general  massage  with  deep  manipulations,  kneading  and 
deep  rubbing,  local  massage  of  the  abdominal  viscera,  through  the  abdominal 
walls,  and  exercises,  including  principally  passive  and  resisted  movements 
of  the  extremities,  are  valuable  therapeutic  agents  in  the  prevention  of  sub- 
involution of  the  uterus  and  abdominal  walls,  and  splanchnoptosis  with  its 
attendant  digestive,  circulatory,  and  nervous  phenomena.  Like  other  remedial 
agents,  such  measures  are  to  be  used  with  care,  and  are  not  applicable  to  all 


698  PHYSIOLOGICAL  PUERPERIUM. 

cases  alike.  Stimulation  of  the  cutaneous  circulation  by  dry  friction  with 
the  hand  or  Turkish  glove  or  by  an  "alcohol  rub"  can  generally  be  used 
with  advantage  after  the  first  day  of  the  puerperium.  In  the  absence  of  com- 
plications, general  massage  with  deeper  manipulations,  kneading,  and  rubbing 
can  be  gradually  introduced  toward  the  end  of  the  first  week  if  the  lochia 
is  not  increased  thereby,  and  in  the  second  week  gradually  increasing  passive 
and  resisted  movements  of  the  extremities  may  be  added.  All  forms  of  septic 
infection,  but  especially  the  thrombotic  variety,  are  contraindications  to  the 
use  of  anything  more  active  than  surface  stimulation. 

(5)  The  Ftrst  Use  of  the  Corset. — It  is  especially  important  in  the  first  use 
of  the  corset  that  a  properly  fitting  garment  be  employed.  At  this  time  espe- 
cially should  the  corsets  which  exert  a  downward  pressure  into  the  pelvis,  and 
form  excessive  pelvic  floor  projection,  retro  displacement,  and  prolapse  of  the 
uterus,  be  avoided.  Corsets  made  to  support  the  lower  abdomen  with  an  upward 
and  backward  pressure  should  be  used  (Figs.  36  and  37). 

7.  The  Examination  of  the  Puerperium. — The  importance  of  routine  examina- 
tion of  the  pelvic  contents  and  noting  the  tonicity  or  sagging  of  the  pelvic  floor 
(levator  ani  muscle)  at  the  completion  of  the  puerperium  cannot  be  overesti- 
mated. If  this  is  made  a  routine,  many  minor  derangements  could  be  corrected, 
which,  if  untreated,  would  become  aggravated  by  time.  A  routine  physical  exam- 
ination of  every  woman  toward  the  close  of  the  puerperium  and  before  she  passes 
out  of  the  observation  of  the  obstetrician  is  of  the  greatest  value  in  detecting 
departures  from  the  normal  process  of  involution  and  in  drawing  attention 
to  them  when  they  are  amenable  to  treatment.  Were  some  simple,  orderly 
method  of  history-keeping  in  obstetric  cases  in  private  practice  adhered  to,  this 
examination  in  the  puerperium  would  readily  become  a  routine  and  give  us  valu- 
able records  for  subsequent  reference.  (See  Appendix.)  The  following  obser- 
vations should  be  made:  (i)  Height  and  position  of  the  fundus  uteri  ;  (2)  con- 
dition of  the  breasts  and  nipples ;  (3)  condition  of  the  pelvic  floor,  perineum, 
and  ostium  vaginse  ;  (4)  quantity  and  quality  of  the  vaginal  .discharge;  (5) 
position,  sensibility,  and  mobility  of  the  uterus;  (6)  condition  of  the  adnexa 
and  perimetrium  and  parametrium;  and  (7)  general  condition  of  the  patient. 


PART    SEVEN. 

Pathological   Puerperium* 


I.  PUERPERAL  HEMORRHAGES.  (Page  701.)  I.  Hematoma  of  the  Vagina 
and  Vulva. 

II.  INTESTINAL  ANOMALIES.  (Page  705.)  1.  Constipation.  2.  Tympanites. 
3.  Hemorrhoids. 

III.  URINARY  ANOMALIES.  (Page  705.)  1.  Hematuria.  2.  Incontinence. 
3.  Retention.    4.  Cystitis.     5.  Pyelonephritis. 

IV.  ANOMALIES  OF  THE  GENITAL  TRACT.  (Page  708.)  1.  Subinvolution. 
2.  Superinvolution.  3.  Atrophy  of  the  Uterus  during  Lactation.  4. 
Uterine  Displacements. 

V.  ANOMALIES  OF  THE  PELVIC  ARTICULATIONS.    (Page  710.) 

VI.  DIASTASIS  OF  THE  ABDOMINAL  MUSCLES.     (Page  711.) 

VII.  MORBIDITY  IN  THE  PUERPERIUM.    (Page  711.) 

VIII.  ANOMALIES  OF  THE  BREASTS.  (Page  759.)  1.  Absence  of  Mammae. 
2.  Hypertrophy.  3.  Lactation  Atrophy  of  the  Breast.  4.  Supernumerary 
Breasts.     Polymastia.     5.  Anatomical  Anomalies  of  the  Nipples. 

IX.  ANOMALIES  OF  THE  MILK  SECRETION.  (Page  760.)  1.  Deficient 
Secretion.  2.  Excessive  Secretion,  Polygalactia,  Hyperlactation,  Galact- 
orrhea.    3.  Qualitative  Anomalies. 

X.  DISEASES  OF  THE  BREASTS.  (Page  761.)  1.  Areolar  Inflammation. 
2.  Congestion  and  Engorgement.  3.  Sore  Nipples.  4.  Inflammation  of 
the   Breasts,  Mastitis.     5.  Qalactocele. 

XI.  BLOOD  CONDITIONS.  (Page  768.)  1.  Thrombosis  and  Embolism. 
2.  Hematoma.     3.  Anemia. 

XII.  DISEASES  OF  THE  NERVOUS  SYSTEM.  (Page  769.)  1.  Lesions  of  the 
Sacral  Plexus.  2.  Puerperal  Neuritis  and  Paralyses.  3.  Hemiplegia  and 
Aphasia.     4.   Myelitis  and  Paraplegia.     5.  Puerperal  Insanity. 

XIII.  SKIN  DISEASES.     (Page  773.) 

XIV.  GENERAL  DISEASES.     (Page  773.) 
XV.  SUDDEN  DEATH.     (Page  773.) 


I.   PUERPERAL   HEMORRHAGES. 

Definition. — Puerperal  hemorrhages  are  those  occurring  any  time  from 
twenty-four  hours  after  the  completion  of  the  third  stage  of  labor  until  the 
period  of  involution  is  complete,  namely  six  weeks.  They  are  also  called 
secondary  or  late  hemorrhages. 

Frequency. — Puerperal  metrorrhagia  depends  largely  upon  the  management 
of  the  third  stage  of  labor,  and  the  care  that  the  puerperal  woman  receives 
during  the  first  few  hours  of  the  lying-in  stage.  Secondary  hemorrhage  is 
not  nearly  so  frequent  as  the  primar>^  post-partum  hemorrhage.  The  amount 
of  lochia  varies  in  different  patients.  In  some  the  duration  of  the  lochial 
discharge  is  longer  and  its  quantity  greater  than  in  others,  and  still  it  is  not 
abundant  enough  to  amount  to  a  secondary  or  remote  post-partum  hemorrhage. 
True  secondary  hemorrhage  is  generally  sudden.  The  quantity  of  blood  varies 
and  the  bleeding  may  cease  for  a  time  and  then  recur.  As  in  primary  post- 
partum hemorrhage  or  flooding,  so  in  the  secondary  variety,  the  hemorrhage 
may  be  entirely  unlooked  for,  and  may  occur  suddenly  without  premonitory 
symptoms  of  any  kind.  The  first  sign  is  the  external  flow  of  blood.  The 
abruptness  of  its  onset  may  preclude  any  opportunity  for  consultation,  and 
if  previous  preparation  for  such  an  emergency  has  not  been  made,  the  result 
may  be  fatal.  Besides  the  hemorrhage,  there  is  often  a  fetid  discharge  resulting 
from  decomposition  of  the  retained  parts.  There  may  also  be  septic  symptoms, 
which  will  offer  an  additional  diagnostic  point. 

Etiology. — The  causes  of  secondary  hemorrhages  may  be  conveniently  divided 
into  general  and  local.  Among  the  general  causes  may  be  classed:  (i)  Disturb- 
ances of  the  general  circulation,  such  as  occur  in  certain  abnormal  conditions 
of  the  heart,  lungs,  or  liver,  and  result  in  the  damming  back  of  the  blood  into 
the  pelvic  vessels,  or  from  the  overuse  of  chloroform  or  stimulants;  (2)  acute 
infectious  diseases;  (3)  peculiar  blood  conditions,  as  in  puerperal  fever,  albu- 
minuria, and  general  malarial  poisoning;  (4)  mental  emotions,  surprises,  shocks, 
joy,  anger,  fright,  such  as  fire  in  the  immediate  neighborhood,  explosions,  or 
sudden  approach  of  an  intoxicated  husband,  producing  vasomotor  changes 
or  a  relaxation  of  the  uterus.  Among  the  local  causes  are:  (i)  Uterine  relaxa- 
tion; (2)  retained  placenta  or  membrane;  (3)  retained  blood-clot;  (4)  a  secon- 
dary placenta;  (5)  secondary  hemorrhage  from  lacerations  of  the  cervix,  vagina, 
or  vulva;  (6)  active  pelvic  congestion;  (7)  displaced  thrombi;  (8)  metritis;  (9) 
fibromata;  (10)  hematomata;  (11)  carcinomata;  (12)  uterine  displacement;  (13) 
distended  bladder  or  rectum. 

1.  Simple  uterine  relaxation  is  of  rare  occurrence  as  a  cause  of  puerperal 
hemorrhage.  It  rarely  occurs  after  the  third  day  of  the  puerperium,  and  is 
usually  caused  by  the  retention  of  debris  in  the  uterine  cavity  or  by  a  defect  in 
the  control  of  the  nervous  system. 

2.  Retained  placenta  or  membrane  results  from  careless  management  or 
an  incomplete  third  stage  of  labor,  and  may  usually  be  prevented  by  careful 
examination  of  the  placenta  and  membranes  at  the  time  of  labor,  and  removal 

701 


702 


PATHOLOGICAL  PUERPERIUM. 


of  retained  fragments.  Small  pieces  of  retained  membrane,  it  should  be  remem- 
bered, do  not  necessarily  produce  puerperal  hemorrhage.  This  is  the  most 
important  cause  of  secondary  hemorrhage  as  well  as  the  most  frequent.  Such 
a  retention  may  be  suspected  if  the  lochial  discharge  is  normal  in  amount  and 
character  at  first,  but  becomes  profuse  and  amounts  to  an  actual  hemorrhage 
after  ten  or  fourteen  days.  The  detachment  of  the  retained  placental  fragments 
is  apt  to  open  one  or  more  of  the  uterine  sinuses. 

3.  Retained  blood  clots  are  common  in  multiparas  and  may  be  prevented  by 
careful  watching  of  the  uterus  for  one  hour  after  the  completion  of  the  third 
stage.  They  are  often  secondary  to  retained  placenta  and  membranes  and  to 
uterine  displacement.     The  clots  can  usually  be  expelled  by  Credo's  method. 

4.  Secondary  placenta,  when  it  exists,  may  in  like  manner  produce  hemor- 
rhage. 

5.  Secondary  hemorrhage  from  lacerations  of  cervix,  vagina,  or  vulva.  Milder 
cases  may  be  treated  with  plain  hot  water  or  acetic  acid  (two  per  cent.);  more 

severe  bleeding  requires  ligation.   (See 
:yr  Part  X.)     The  lacerations  in  the  peri- 

neum and  vulva  are  generally  appar- 
ent, but  sometimes  those  in  the  vagina 
are  not  visible  without  special  exam- 
ination. Tears  of  the  cervix  some- 
times extend  to  the  vaginal  fornix  and 
at  times  through  a  venous  sinus. 

6.  Active  or  passive  pelvic  conges- 
tion. Active  pelvic  congestion  may  be 
produced  by  moving  about  too  soon 
after  labor  or  by  too  early  sexual  in- 
tercourse. Passive  congestion  may 
result  from  subinvolution,  increasing 
and  prolonging  the  red  lochia,  or  may 
be  due  to  obstruction  to  the  return 
circulation ;  or  it  may  come  from  vari- 
cosity of  the  pampiniform  plexus  or 
from  disease  of  the  adnexa.  General 
diseases  in  this  connection  have  been 
noted  above.  (See  Postpartum 
Hemorrhage.) 

7.  Displaced  thrombi  may  occur  primarily  as  the  result  of  rapid  heart 
action  and  high  arterial  tension  following  labor,  or  secondarily  from  septic 
disintegration  of  thrombi  formed  in  the  uterine  sinuses.  This  accident  may 
also  occur  from  sudden  strain,  or  from  turning  in  bed  or  sitting  up. 

8.  Metritis.  This  inflammatory  condition  of  the  uterus  sometimes  makes 
it  prone  to  bleed  easily.     (See  Metritis,  page  730.)  I^lf'' fil 

9.  Fibromata  are  liable  to  cause  excessive  and  prolonged  red  lochia  and 
may  produce  violent  hemorrhage.  Mucous  polypi  may  also  have  the  same 
effect  (Fig.  925). 

10.  A  hematoma  is  an  internal,  interstitial,  or  concealed  hemorrhage, ^which 
may  be  submucous,  subcutaneous,  or  subperitoneal.  As  a  rule,  it  doesjnot 
require  treatment.* 

11.  Carcinoma  is  usually  seated  in  the  cervix  and  may  require  curettage 
and  packing.  Malignant  disease  of  the  uterus,  as  a  rule,  hinders  or  prevents 
conception,  consequently  this  condition  is  rare. 

*  See  N.  Y.  Obstet.  Soc.,  April,  1901. 


Fig.  925. — Fibrinous  Polypus  of  the  Puer- 
peral Uterus. — (Frdnkel.) 


PUERPERAL  HEMORRHAGES.  703 

12.  Uterine  displacement  may  be  caused  by  overdistended  bladder,  pro- 
longed dorsal  position,  getting  up  too  early,  or  sudden  effort  on  the  part  of 
the  patient.  Backward  displacement  is  the  most  common.  The  heavy  uterus 
is  in  a  condition  to  be  easily  displaced  and  the  direction  varies  widely.  Any 
cause  hindering  the  normal  involution  of  the  uterus  tends  toward  this  result. 
Immediately  after  labor  the  uterus  is  freely  movable,  and  confinement  of  the 
patient  to  one  position  or  the  imperfect  application  of  binders  is  most  injurious. 
An  abnormal  flexion  of  the  uterus  will  cause  a  retention  of  the  secretions  until 
the  occurrence  of  putrefactive  changes.  Immediately  after  labor  the  normal 
position  of  the  uterus  is  increased  anteversion  with  a  slight  prolapse.  When 
inversion  takes  place,  it  is  usually  very  soon  after  labor,  and  may  follow  some 
severe  strain.  It  must  be  differentiated  from  a  polypoid  tumor.  Retroflexion  or 
retroversion  is  often  caused  by  the  application  of  a  tight  binder  before  the  uterus 
has  returned  to  its  normal  position  below  the  pubis,  the  pressure  on  the  abdo- 
men forcing  the  organ  backward.  Subinvolution  from  any  cause  may  produce 
this  anomaly.  Prolapse  may  occur  from  great  straining,  especially  when  labor 
has  been  attended  by  marked  injuries. 

13.  A  distended  bladder  or  rectum,  especially  the  former,  may  act  as  a 
cause  (Fig.  926). 

Symptoms. — These  are  general  and  local,  the  former  being  those  characteristic 
of  hemorrhage  in  general — pallor,  weakness,  dimness  of  vision,  small,  thready 
pulse,  tendency  to  syncope,  cold  perspiration.  The  local  symptoms  are  a  soft- 
ened condition  of  the  uterus  and  an  internal  and  external  hemorrhage,  although 
at  first  the  latter  may  not  appear. 

Prognosis. — The  amount  of  hemorrhage  may  vary  within  wide  limits  and 
the  loss  of  blood  may  occur  gradually  or  in  a  sudden  gush.  The  great  danger 
from  puerperal  hemorrhage  lies  in  the  opportunities  for  infection,  which  always 
threatens  the  puerperal  woman,  since  the  gaping  vessels  afford  such  an  easy 
port  of  entry  to  septic  products. 

Treatment. — This  must  vary  with  the  cause.  As  in  primary  hemorrhage, 
the  best  treatment  is  preventive.  All  the  general  and  local  causes  of  the  accident 
should  be  prevented,  or  if  present  they  should  be  corrected.  The  lying-in 
woman  should  be  protected  against  (i)  mental  emotions;  (2)  disturbances  of 
the  general  circulation  ;  and  (3)  blood  conditions  that  might  cause  a  hemor- 
rhage during  the  puerperal  state.  If  the  third  stage  of  labor,  as  well  as  the  first 
few  days  of  the  puerperium,  is  properly  managed  there  will  be  avoided  (i) 
the  retention  of  placental  tissues,  (2)  of  membranes,  and  (3)  of  blood-clots,  and 
(4)  a  distended  bladder  or  rectum.  The  patient  should  be  kept  quietly  in  bed 
till  involution  is  complete  and  sexual  intercourse  should  be  prohibited  for  two 
months.  The  curative  treatment  of  this  condition  consists,  as  in  primary' 
hemorrhage,  in  making  sure  that  the  uterus  is  completely  emptied,  and  in 
securing  complete  contraction.  A  vaginal  examination  should  always  be  made, 
and,  if  the  cervical  canal  allow  it,  the  uterine  cavity  explored  and  any  retained 
material  removed.  If  the  cervix  will  not  allow  of  the  passage  of  the  finger 
and  the  hemorrhage  is  profuse,  the  canal  must  be  dilated  and  the  interior  of 
the  uterus  examined.  Should  the  evacuation  of  the  uterus  not  stop  the  bleeding 
its  interior  should  be  swabbed  out  with  a  2  per  cent,  acetic-acid  solution — or 
the  plan  of  irrigating  the  uterus  with  hot  water  at  a  temperature  of  110°  F. 
may  be  tried.  The  contracted  state  of  the  cervix  may  prevent  the  proper 
outflow  of  the  water,  and  this  must  be  guarded  against  by  using  a  small  intra- 
uterine tube  or  return-flow  tube  and  first  securing  ample  dilatation  of  the 
cervical  canal.     If  there   are  symptoms   of  septicemia,   creolin  injections   are 


704  PATHOLOGICAL  PUERPERIUM. 

excellent.  Ergot,  one  to  two  drachms,  with  tincture  of  cannabis  indica  fifteen 
minims,  is  indicated  and  may  be  repeated  as  necessary.  Rest,  both  physical 
and  mental,  must  be  insisted  upon,  while  tonics  and  a  nutritious  Hquid  diet 
will  be  subsequently  needed.  If  relaxation  of  the  uterus  is  the  cause,  packing 
the  uterine  cavity  with  gauze  is  the  best  treatment.  (See  Part  X.)  This  is 
also  used  in  the  case  of  sepsis  or  displaced  thrombi.  And  here  the  curette 
must  not  be  employed.  Uterine  polyps  should  be  removed.  Faradism  is  of 
some  value.  A  hard  bed  and  a  cool  room  should  be  provided,  and  the  rectum 
and  bladder  should  be  emptied  by  enema  and  catheter  if  necessary. 

I.  Hematoma  of  the  Vagina  and  Vulva. — Definition. — An  extravasation  o 
blood  into  the  subcutaneous  and  submucous  tissue  of  the  vulva,  extending  in 
some  cases  into  the  perineum  as  far  as  the  anus,  or  into  the  paravaginal  tissue 
as  far  as  the  abdominal  cavity.  Etiology. — The  predisposing  factor  is  the  vascul- 
arity of  the  tissues  in  the  pregnant  state,  with  the  varicosity  of  the  pudendal 
veins.  Exciting  causes  are  usually  connected  with  delivery,  as  in  manual  and 
instrumental  extraction.  Since  the  fetal  head  exerts  a  hemostatic  action  during 
its  birth,  the  hematoma  becomes  in  evidence,  as  a  rale,  during  the  third  stage 
of  labor.  Sometimes  it  happens  that  the  extravasation  precedes  labor  as  a  re- 
sult of  some  act  of  violence.  In 
twin  pregnancy  it  is  not  uncommon 
to  see  a  hematoma  follow  the  birth 
of  the  first  child,  and  constitute  an 
obstacle  to  the  passage  of  the  other 
twin.  Pathology. — The  extravas- 
ated  blood  tends  to  coagulate  at 
once,  and  the  hemorrhage  usually 
■"  becomes  arrested  before  it  becomes 
extensive.  The  oozing,  as  a  rule, 
ceases  after  two  or  three  hours. 
Exceptionally,  hemorrhage  con- 
tinues intermittently  for  a  much 
Fig.  926.— Hematoma  of  Vagina  and  Vulva.  longer  period.  The  tendency  is 
— {Hill. J  toward     resolution,     effected    by 

gradual  absorption,  which  is  com- 
pleted in  four  or  five  weeks.  Rupture  often  occurs,  especially  when  the 
hematoma  precedes  the  second  stage  of  labor;  there  is  then  danger  of  infection. 
Symptoms. — The  extravasation  is  accompanied  by  pain,  which  varies  greatly 
in  degree  and  kind.  A  tumor  forms  rapidly,  usually  on  one  side  of  the  vulva, 
having  a  dusky  or  livid  color.  As  a  rule,  some  tenesmus  of  the  bladder,  rectum, 
or  both  coexists.  If  the  extravasation  is  in  the  paravaginal  tissue  alone,  no  ex- 
ternal tumor  is  apparent.  Non-appearance  of  the  lochial  discharge  should 
suggest  such  an  accident.  Diagnosis. — The  tumor  when  suspected  is  mapped 
out  by  inspection  and  by  digital  exploration  of  the  vagina  and  rectum.  Since 
there  is  always  a  zone  of  edema  about  the  extravasation  proper,  an  ede- 
matous area  ma}'-  conceal  a  small  hematoma.  Hematoma  has  been  mistaken 
for  a  variety  of  conditions,  such  as  inversion  of  the  uterus,  cysts  of  the  vagina, 
etc.  Prognosis. — At  the  present  antiseptic  period  this  is  favorable,  but  even 
to-day  the  mortality  is  computed  at  12  per  cent.  The  chief  cause  of  death  is 
profuse  hemorrhage,  which  is  usually  the  result  of  rupture  of  a  vaginal  hematoma 
which  precedes  the  second  stage  of  labor.  The  likelihood  of  a  fatal  hemorrhage 
is  fully  as  great  here  as  in  placenta  prsevia.  Treatment. — In  hematoma  antedat- 
ing the  second  stage  of  labor,  interference  despite  the  danger  of  rupture,  is  con- 


INTESTINAL  ANOMALIES— URINARY  ANOMALIES.  705 

traindicated,  unless  the  tumor  actually  obstructs  the  birth  of  the  child.  The 
mass  should  then  be  -incised  and  the  clots  extracted.  The  cavity  should  be 
packed  with  gauze  after  securing  all  bleeding  vessels.  In  very  large  hema- 
tomata,  which  threaten  to  rupture  spontaneously  in  the  puerperium,  from 
the  effects  of  pressure,  incision  and  packing  should  also  be  practised.  Under 
all  other  conditions,  treatment  should  be  expectant.  Pressure  and  cold  appli- 
cations should  be  used  to  arrest  further  hemorrhage  and  promote  absorption. 


II.   INTESTINAL  ANOMALIES. 

1.  Constipation. — This  is  the  rule  in  the  puerperium,  and  is  caused  by  weak- 
ened musculature  of  the  abdominal  parietes  and  intestinal  muscle-coats  and  by 
the  prolonged  rest  in  bed.  This  condition  often  causes  fever,  possibly  from  the 
absorption  of  animal  alkaloids.  Evacuation  of  the  bowels  should  occur  by  the 
end  of  the  third  day  (unless  there  has  been  a  complete  suture  of  the  perineum, 
when  treatment  should  be  deferred  until  the  fourth  day),  and  the  administration 
of  laxatives  during  this  period  is  not  necessary  if  the  bowels  were  well  opened 
before  labor.  But  if  no  movement  occurs  in  this  time  and  diet  seems  to  have 
no  effect,  it  is  well  to  try  a  simple  injection  of  water,  to  which  a  little  glycerin 
may  be  added.  For  not  only  the  mother's  condition  must  be  taken  into  con- 
sideration, but,  if  she  nurses  her  child,  the  latter  demands  equally  careful  con- 
sideration. If  the  injection  is  not  effective,  castor  oil,  calomel,  a  saline  laxative, 
or  the  well-known  combination  of  aloin,  strychnin,  and  belladonna  maybe  given. 
The  regular  action  is  then  generally  established,  although  an  obstinate  constipa- 
tion may  persist  which  will  demand  much  skill  to  overcome. 

2.  Tympanites. — There  sometimes  occurs  in  neurotic  women  an  excessive 
amount  of  gas  in  the  intestines  following  a  sudden  paralysis  of  their  muscu- 
lature. The  abdomen  is  greatly  distended,  so  that  there  may  be  true  orthopnea 
from  upward  pressure  of  the  diaphragm,  and  there  is  obstinate  vomiting  with 
persistent  constipation  and  other  signs  of  obstruction  of  the  bowels.  There 
are  no  symptoms  of  peritonitis,  but  there  is  a  serious  outlook  for  the  patient's 
life,  demanding  radical  treatment.  Nerve  sedatives,  large  hypodermic  doses 
of  strychnin,  enemata  of  asafetida  and  turpentine,  and  gentle  cathartics  by 
the  mouth  are  all  indicated.  If  these  measures  fail,  the  rectal  tube  and  high 
enemata  may  be  used. 

3.  Hemorrhoids. — Pregnancy  may  cause  such  a  degree  of  congestion  of  the 
rectal  veins  that  it  may  persist  after  labor.  This  condition  may. show  itself 
only  during  the  period  of  parturition  or  it  may  persist  afterward.  The  pain 
is  very  severe.  Ulceration  and  gangrene  may  result.  In  treating  this  con- 
dition the  bowels  must  be  kept  regular,  and  either  hot  or  cold  local  applications 
will  relieve  the  pain.  Astringent,  sedative  suppositories  sometimes  give  relief, 
as  belladonna,  opium  and  lead,  and  compound  ointment  of  gall.  If  strangu- 
lation occurs,  the  tumors  must  be  excised. 


III.  URINARY   ANOMALIES. 

I.  Hematuria. — This  condition  in  the  puerperium  generally  follows  a  hemor- 
rhoidal condition  of  the  vesical  veins  induced  by  pelvic  congestion  in  the  last 
part  of  pregnancy.     It  may  be  due  also  to  injurv  from  pressure  of  the  child's 
45 


706 


PATHOLOGICAL  PUERPERIUM. 


head  or  from  instruments  or  the  result  of  vesico-vaginal  fistulae.  The  differential 
diagnosis  may  be  made  from  the  history.  Blood  when  present  in  the  urine 
generally  disappears  spontaneously  in  a  few  days,  but  occasionally  astringent 
injections  are  necessary.  Unusual  care  should  be  observed  at  this  time  in  the 
use  of  the  catheter. 

2.  Incontinence  of  Urine. — Incessant  dribbling  may  be  due  to  paralysis  of 
the  sphincter  or  to  fistulse.  If  the  urine  escapes  involuntarily  soon  after  delivery, 
an  examination  should  be  made  at  once.  If  there  are  also  present  severe  abdom- 
inal pains  and  the  urine  escapes  a  few  drops  at  a  time,  or  with  an  occasional  gush 
or  spurt,  there  will  be  grounds  for  the  diagnosis  of  incontinence  of  retention.  Ex- 
amination will  reveal  a  median  abdominal  tumor  having  a  dull  percussion  note. 
The  catheter  will  empty  the  bladder  and  relieve  the  distention.  If,  however, 
there  is  no  pain  on  the  escape  of  urine,  and  if  labor  has  been  abnormal,  a  fistula 

will  probably  be  discov- 
ered. When  this  is  very 
small,  it  may  heal  spon- 
taneously. But  if  this  is 
impossible,  a  plastic  oper- 
ation may  be  necessary 
later.  Rarely  pressure 
paralysis  of  the  vesical 
sphincter  and  the  urethra 
may  be  the  cause  of  this 
trouble.  Such  cases  some- 
times do  not  seem  amen- 
able to  treatment  of  any 
kind,  though  tonics,  elec- 
tricity applied  to  the  ure- 
thra, and  massage  may  be 
successful. 

3.  Retention  of  Urine. 
— After  labor  retention  of 
urine  is  very  common, 
and,  indeed,  may  be  ex- 
pected for  a  few  hours. 
This  is  caused  by  the  ex- 
pansion of  the  bladder 
and  its  loss  of  sensibility 
after  the  uterus  has  expelled  its  contents,  and  often  by  the  cessation  of  action  of 
the  abdominal  muscles.  There  may  also  be  a  real  obstruction  from  traumatism 
of  the  urinary  apparatus,  especially  the  urethra.  Before  resorting  to  the  use  of  the 
catheter,  which  is  always  attended  with  some  risk  of  bladder  infection,  all  other 
known  means  for  relieving  the  condition  should  be  tried,  as  the  sound  of  running 
water,  allowing  a  stream  of  warm  water  to  flow  over  the  vulva  into  a  douche  pan, 
the  application  of  hot  chloroform  stupes  to  the  vulva,  and,  if  not  contraindicated, 
allowing  the  patient  to  assume  the  sitting  posture  in  bed  on  the  vessel  or  douche 
pan.  If  this  last  procedure  is  permitted  in  the  first  twenty-four  hours  of  the 
puerperium,  the  nurse  should  be  instructed  carefully  to  watch  the  fundus  uteri 
during  the  evacuation  of  the  bladder.  Whatever  the  cause,  a  period  not  longer 
than  eighteen  hours  should  be  allowed  to  pass  before  the  patient  is  catheterized, 
and  in  this  operation  all  possible  antiseptic  precautions  should  be  taken.  Reten- 
tion is  most  common  after  suture  of  the  perineum.     The  bladder  may  be  injured 


Fig.   927. — Retention  of  Urine  and   Distended  Blad- 
der   DURING    THE    EaRLY    PaRT    OF    THE     PuERPERIUM. 


URINARY  ANOMALIES.  707 

by  retention  and  uterine  hemorrhage  occur  from  the  excessive  distention  of 
the  organ.     (See  Puerperal  Hemorrhage,  page  701.)      (Fig.  927.) 

4.  Cystitis. — This  is  unfortunately  quite  common  in  the  puerperium  and  is 
a  serious  affection  of  the  urinary  system  to  be  guarded  against,  since  it  may 
lead  to  a  fatal  result.  Frequently  it  does  not  pass  beyond  the  mild  form, 
and  its  duration  is  then  only  transitory.  Etiology:  The  common  cause  is 
careless  introduction  of  the  catheter.  This  should  always  be  done  under 
the  strictest  antiseptic  precautions.  The  urethral  orifice  should  never  be 
sliielded  by  the  bed-sheet,  but  ought  in  all  cases  to  be  perfectly  exposed  to 
the  view  of  the  operator.  Again,  though  rarely,  overdistention  of  the  bladder 
or  pressure  of  the  child's  head  may  injure  the  vesical  walls  sufficiently  to  cause 
a  catarrhal  cystitis.  This  type  is  generally  of  short  duration  unless  an  intro- 
duction of  micro-organisms  takes  place.  Under  these  circumstances  the  simple 
lesion  may  develop  into  a  suppurative  inflammation  which  does  not  limit 
itself  to  the  bladder,  but  extends  along  the  ureters  to  the  kidneys  and  ends 
in  disease  of  these  organs.  Even  when  the  catheter  is  not  used  there  may 
be  migration  of  vaginal  micro-organisms  into  the  urethra,  and,  according  to 
some  authorities,  micro-organisms  from  the  various  pelvic  viscera  may  find 
their  way  into  the  bladder.  Symptoms:  The  symptoms  of  the  milder  type  are 
those  of  an  ordinary  cystitis:  viz.,  frequent  urination,  discomfort,  burning  pain, 
and  alkaline  urine.  With  the  development  into  the  septic  form,  the  symptoms 
increase  in  severity,  especially  with  the  extension  of  the  disease  to  the  ureters. 
Sometimes  delirium  occurs,  the  temperature  is  high,  and  anemia  and  prostra- 
tion are  extreme.  The  constant  desire  to  urinate  gives  rise  to  great  distress. 
The  condition  of  the  bowels  is  quite  variable. 

Urinary  examination  shows  the  amount  to  be  small,  the  specific  gravity 
low,  reaction  acid.  The  microscopic  examination  reveals  epithelium  of  several 
varieties,  pus-  and  blood-corpuscles,  urates  and  uric  acid  crystals.  The  mucous 
membrane  may  exfoliate  and  pass  off  in  the  urine.  In  such  severe  cases  the 
presence  of  albumin  and  tube  casts  will  be  detected.  The  prognosis  of  this 
affection  will  depend  upon  prompt  attention  and  careful  treatment.  The  great 
danger  lies  in  extension  to  the  kidneys.  Prophylaxis  is  most  important.  After 
its  occurrence  the  bladder  should  be  irrigated  several  times  a  day  with  boric- 
acid  solution;  creolin,  0.5  per  cent.,  or  sublimate,  i  :  20,000,  is  sometimes  used. 
The  internal  administration  of  salol,  urotropin,  boric  or  benzoic  acid  and  buchu 
is  also  advisable,  as  these  drugs  affect  the  quality  of  the  urine.  The  patient's 
strength  and  general  tone  must  be  kept  up  by  tonics  and  stimulants  as  well  as 
by  nourishing  food.     Subsequently  change  of  climate  is  often  beneficial. 

5.  Pyelonephritis. — This  may  occur  from  the  extension  of  the  vesical  lesion 
along  the  ureters  to  the  pelvis  of  the  kidney.  There  are  cases  in  which  the 
bladder  trouble  is  so  slight  that  it  is  not  noticed,  and  it  is  only  the  lighting-up 
of  the  renal  inflammation  that  draws  attention  to  the  disturbance.  This 
infection  may  also  be  caused  by  the  irritation  of  renal  calculi  or  may  occur 
from  the  blood.  The  prognosis  is  doubtful,  many  cases  ending  fatally.  The 
treatment  is  essentially  the  same  as  in  cystitis,  with  the  addition  oftentimes 
of  incision  of  the  pelvis  of  the  kidney  or  of  the  perinephritic  abscess,  in  case  the 
latter  develops.  Post-mortem  examination  has  shown  the  kidney  to  be  involved 
as  a  whole,  forming  a  large  bag  of  pus,  or  to  be  honeycombed  throughout  with 
tiny  abscesses. 


708  PATHOLOGICAL  PUERPERIUM. 


IV.   ANOMALIES   OF  THE   GENITAL  TRACT. 

I.  Subinvolution. — Subinvolution  is  a  retarded  or  incomplete  involution  of 
the  uterus.  The  normal  process  requires  generally  from  six  to  ten  weeks. 
Pathology:  The  process  of  involution  is  one  of  fatty  degeneration,  absorption, 
and  atrophy.  It  is  not  believed  that  the  whole  muscle  cell  is  destroyed  by 
fatty  degeneration,  but  rather  that  atrophy  accompanies  the  fatty  process 
and  ceases  after  the  muscle  fiber  reaches  its  original  size.  The  uterine  adnexa, 
vagina,  and  vulva  undergo  the  same  process.  (See  Part  VI.)  It  can  readily  be 
seen  how  slight  influences,  either  acting  directly  on  the  uterus  or  through  the 
mother's  blood,  can  Interfere  with  the  process  of  involution,  resulting  in  the 
pathological  condition  known  as  subinvolution.  Arrested  involution  depends 
entirely  upon  changes  in  the  circulation  of  the  uterus  or  its  vicinity ;  congestion, 
either  active  or  passive,  being  the  important  etiological  factor.  Etiology:  (i) 
Causes  interfering  with  the  proper  contraction  and  retraction  of  the  uterine 
muscle  or  with  its  blood-supply  must  be  looked  for  as  originating  the  condition 
of  subinvolution.  As  a  rule,  these  causes  are  local,  though  there  are  a  few  ex- 
ceptions. Among  the  local  causes  may  be  mentioned:  habitual  distention  of  the 
bladder  or  rectum,  retained  secundines,  displacement  of  the  uterus,  fibroid 
or  polypoid  tumors,  or  old  peritoneal  adhesions.  (2)  Causes  either  increasing 
the  blood-supply  to,  or  obstructing  the  return  flow  from,  the  uterus  are: 
inflammatory  conditions  subsequent  to  septic  processes,  fibroid  and  other 
pelvic  tumors,  retained  hypertrophied  decidua  as  in  incomplete  abortion. 
Endometritis  from  other  causes,  cardiac  and  pulmonary  disease,  inflammatory 
conditions  interfering  with  pelvic  circulation,  and  all  the  causes  of  obstructed 
portal  circulation  also  belong  under  this  head.  Nervous  disorders,  such  as 
puerperal  insanity  or  a  great  shock,  not  infrequently  retard  involution. 
Too  early  sexual  intercourse  after  abortion  or  delivery  may  not  only 
hinder  but  arrest  involution.  Women  who  do  not  nurse  their  children 
are  more  prone  to  this  abnormality.  It  has  been  held  by  some  that 
constitutional  disturbances  having  no  connection  with  any  local  cause 
may  furnish  the  etiological  factor.  The  local  cause,  however,  should  al- 
ways be  carefully  looked  for.  Diagnosis :  An  early  diagnosis  is  important, 
in  order  to  avoid  the  numerous  disorders  which  are  so  likely  to  follow  sub- 
involution. Abdominal  palpation  will  detect  approximately  any  defect  in  the 
involution  of  the  uterus;  later,  however,  the  diagnosis  is  generally  made  by 
the  gynecologist.  The  uterus  is  large,  boggy,  soft,  and  tender  on  pressure. 
The  size  of  the  organ  does  not  correspond  to  the  period  of  the  puerperium. 
Symptoms:  These  include  a  feeling  of  weight  in  the  pelvis,  lochia  profuse  and 
red,  or  serous  lochia  changing  to  bloody  lochia  late  in  puerperium,  backache, 
reflex  symptoms,  pain  or  tenderness  over  the  lower  portion  of  abdomen.  Irrita- 
ble bladder  or  rectum  may  be  present  if  acute  displacement  exists.  Treatment: 
The  prophylactic  treatment  of  subinvolution  is  most  important  to  save  the  pelvic 
organs  from  various  subsequent  gynecological  conditions.  (See  Management  of 
the  Puerperium,  Part  VI.)  The  curative  treatment  must  depend  upon  the 
cause.  If  this  is  retention  of  placental  or  decidual  tissue,  the  uterus  should  be 
curetted  and  disinfected.  If  there  are  lacerations  of  the  cervix  or  vagina,  they  will 
have  to  be  repaired.  Displacement  of  the  uterus  should  be  remedied  by  a  suitable 
pessary,  which  is  to  be  changed  from  time  to  time  as  the  organ  decreases  in 
size.  A  pelvic  tumor  may  be  removed.  The  general  functions  of  the  body 
must  be  maintained  by  hygienic  measures.     Massage  of  the  uterus  may  assist 


ANOMALIES   OF   THE  GENITAL   TRACT. 


709 


it  to  return  to  its  natural  size.  When  the  amount  of  lochia  is  excessive,  hot 
vaginal  douches  should  be  given.  The  pelvic  viscera  should  be  depleted  by 
hot  injections  and  vigorous  catharsis.  Ergot  is  sometimes  employed  when  it 
seems  especially  indicated  by  muscular  weakness  or  the  presence  of  small 
fibroids.     Tonics  and  electricity  are  at  times  beneficial. 

2.  Superinvolution,  Hyperinvolution. — A  condition  known  as  superinvoluiion 
or  hyperinvolution,  depending  upon  a  prolongation  of  the  fatty  degeneration 
and  atrophy  of  the  parturient  uterus,  has  been  known  to  exist.  It  is  very 
infrequent.  In  very  rare  cases  the  uterus  may  almost  disappear.  It  is  prob- 
ably the  result  of  profound  anemia;  protracted  lactation  may  coexist.  The 
symptoms  are  usually  not  pronounced.  Menstruation  may  not  return.  Diag- 
nosis should  be  made  by  bimanual  examination.  For  treatment,  the  child  must 
be  weaned,  tonics  administered,  the  diet  made  nutritious  and  generous,  and 
hygienic  measures  instituted,  such  as  a  change  of  air  and  scene,  with  massage 
or  carefully  regulated  exercises. 

3.  Atrophy  of  the  Uterus  during  Lactation. — This  condition  is  not  to  be 
confounded  with  hyperinvolution,  which  is  pathological  in  character.     I  mean 


Bladda 
Ut.ve^  verinenm 
Poslsriar  Van.  rcm/y 
iaijms  caveiTwsun  ei  im  Cluori 

Urethra  ~ 
AmerterVao.  fornLx  ^ 

Anterior  cavica/Lifi— 
Vaolna  — 
MroBuis  vaninGe. 
External  oi 
Penr"'  m 


Rt  Com.  I  Hoc  Artery 
Lefl  Com.  II lot  Vein 


m  Sacral  Vert 
Zervical  Canal 
Fundus  uteri 
Left  Homei  L'terui 
-  Hectum 


Anil'  /^  V 

mtaiuit  .ptiLncicj-     /  • 
"External  ^mwter 


Fig.    928. — Retroflexion    of   the    Puerperal    Uterus    in    a    Multipara. — (Sellheim.) 


by  lactation-atrophy  a  physiological  phenomenon  which  appears  to  be  due 
chiefly  to  nursing  alone.  This  subject,  rarely  mentioned  by  obstetricians,  has 
been  described  by  Vineburg. 

It  is  known  that  in  connection  with  involution  the  uterus  becomes  smaller 
at  one  period  than  even  the  non-parous  organ;  and  that  it  undergoes  regener- 
ation either  during  or  after  the  lactation  period.  The  period  of  minimum  size 
has  been  placed  by  various  authorities  at  any  time  between  six  and  twenty 
weeks.  This  phenomenon  is  best  seen  in  the  multipara,  and  is  much  less 
marked  in  primiparae.  Although  known  as  lactation-atrophy,  something  of  the 
same  sort  is  seen  in  mothers  who  do  not  nurse  their  children,  although  in  a 
much  less  degree. 

If  the  uterus  is  studied  microscopically  during  this  period,  the  muscular 
fibers  are  seen  to  have  undergone  atrophy,  while  the  usual  fatty  changes  of  in- 
volution are  also  in  evidence.  The  part  played  by  the  ovaries  in  this  connection 
is  not  known.  In  very  high  degrees  of  lactation-atrophy  there  should  be  a 
suspicion  that  the  ovaries  are  in  some  way  involved.  A  normal  condition 
should  not  give  rise  to  pathological  symptoms,  yet  during  this  stage  of  minimal 


710  PATHOLOGICAL  PUERPERIUM. 

size  the  patients  almost  always  complain  of  backache  and  vague  pelvic  pains. 
Other  symptoms,  such  as  leucorrhea,  are  absent,  this  going  to  show  that  the 
condition  is  not  necessarily  pathological. 

A  typical  case  gives  the  following  clinical  picture :  A  woman  during  the  lacta- 
tion period  develops  backache  and  pelvic  pain,  without  leucorrhea  or  other  symp- 
tonris.  Examination  shows  an  undersized  uterus.  Although  this  atrophy  is 
physiological  and  should  be  succeeded  by  regeneration,  cases  are  not  wanting  in 
which  the  latter  does  not  set  in.  The  condition  then  may  become  permanent, 
but  differs  from  hyperin volution,  through  the  fact  that  weaning  the  child  may 
be  followed  by  recovery.  As  a  prevention  it  has  been  suggested  that  weaning 
should  occur  after  the  seventh  month,  in  order  to  save  the  uterus  from  damage. 

4.  Uterine  Displacements. — (i)  Inversion.  (See  Pathology  of  Labor,  page 
590.)  (2)  Prolapse:  The  degree  of  this  displacement  varies  to  a  great  extent. 
When  the  injuries  during  birth  have  been  severe,  some  great  strain  during 
the  puerperium,  such  as  lifting  a  heavy  weight,  causes  occasionally  a  pro- 
lapse of  the  puerperal  uterus.  The  latter  is  greatly  increased  in  weight 
and  deficient  in  muscular  tone,  both  conditions  favoring  displacement.  (3) 
Retroflexion  and  retroversion  (Fig.  928):  Retroflexion  and  retroversion  are  most 
commonly  found  in  women  who  have  suffered  from  these  displacements  before 
conception  and  in  those  who  have  aborted.  A  sudden  strain,  failure  to  empty 
the  bladder  when  the  desire  is  felt,  and  the  use  of  tight  binders,  as  noted 
before,  may  all  contribute  to  these  forms  of  displacement.  These  patients 
should  stay  in  bed  longer  than  usual  and  they  should  lie  on  the  side  as  much 
as  possible.  In  the  latter  part  of  the  puerperium  astringent  douches  should 
be  given.  (4)  Anteflexion  and  anteversion :  Extreme  anteversion  or  anteflexion 
may  also  occur  in  the  puerperium;  the  latter  especially  will  cause  a  reten- 
tion of  the  uterine  secretions.  Other  abdominal  organs  are  also  sometimes 
displaced  during  the  puerperium;  floating  kidney  may  be  mentioned  as  an 
example. 


V.   ANOMALIES   OF  THE   PELVIC  ARTICULATIONS. 

The  joints  affected  are  the  symphysis  pubis  and  sacro -iliac  synchondroses. 
The  cause  is  sometimes  pathological  change,  sometimes  the  violent  use  of  the 
forceps,  or  a  combination  of  the  two.  These  joints,  as  has  already  been  noted, 
become  relaxed  in  normal  pregnancy  so  that  they  allow  a  slight  amount  of 
movement  of  the  bones  on  one  another.  Various  etiological  factors  are  men- 
tioned by  different  authorities,  besides  those  noted  above,  among  which  are 
extreme  exertion  on  the  part  of  the  patient,  pressure  of  a  large  fetal  head, 
and  traumatism,  which  may  cause  inflammation.  There  is  hyperemia  and 
swelling  of  the  synovial  membrane  and  an  increased  secretion  of  the  synovial 
fluid  until  the  extremities  of  the  bones  become  separated  from  each  other.  If 
this  condition  becomes  more  serious,  the  formation  of  pus  takes  place  and  abscess 
develops.  The  bone  is  gradually  eroded  and  even  becomes  carious.  Complete 
rupture  of  the  joints  of  the  pelvis  may  occur.  Symptoms:  These  are  noticed 
when  the  patient  first  gets  up  and  tries  to  walk.  There  is  pain,  extending 
into  the  lower  extremities,  and  increased  mobility  of  the  articulations.  The 
latter  fact  can  be  proved  by  manual  examination.  The  patient  probably 
walks  with  difficulty.  However,  there  may  be  considerable  movement  and 
little  impairment   of  walking,   or  there  may  be  slight  movement   only,   with 


MORBIDITY  IN   THE  PUERPERIUM.  711 

much  pain  and  lameness.  The  gait  is  very  like  that  of  the  osteomalacic  patient. 
In  case  of  suppuration  the  symptoms  are  greatly  intensified,  chill  and  fever 
come  on,  abscesses  of  the  soft  parts  develop,  and  the  patient  becomes  unable 
to  move  the  legs.  Relapse  is  not  unlikely  to  occur  in  the  next  pregnancy. 
In  rare  instances  septicemia  or  pyemia  results.  Diagnosis:  This  is  easily 
made  from  a  few  characteristic  symptoms.  The  pain  can  always  be  exactly 
located  by  the  patient  in  the  diseased  joint.  There  is  tenderness  on 
pressure  or  motion.  The  usual  symptoms  of  suppuration  indicate  its  pres- 
ence. The  prognosis  is  favorable  in  simple  cases,  but  increases  in  gravity 
with  the  development  of  suppuration.  Treatment:  Rest  in  bed  in  the  dorsal 
position  and  a  strong,  firm  bandage,  whose  upper  border  is  level  with  the  iliac 
crests  while  the  lower  reaches  just  below  the  trochanters  (Fig.  919).  The 
patient  may  then  walk  around  as  she  would  ordinarily,  even  if  there  is  pain. 
The  condition  generally  terminates  in  recovery,  the  bones  becoming  fixed  after 
some  months,  but,  in  a  very  few  cases,  this  does  not  happen  and  the  bandage 
has  to  be  worn  continuously.  When  the  pain  is  severe,  the  ice-bag  is  indicated. 
Narcotics  may  also  be  given.  The  disease  may  become  chronic,  and  in  that 
case  change  of  climate,  sea-bathing,  mild  counterirritation,  and  continuous 
tight  bandaging  may  be  efficacious. 


VI.    DIASTASIS   OF   THE  ABDOMINAL  MUSCLES. 

In  patients  whose  abdomens  have  been  unusually  distended  or  whose 
abdominal  muscles  are  weak,  and  especially  in  those  who  have  borne  many 
children,  the  recti  are  not  infrequently  separated.  This  condition  sometimes 
allows  the  protrusion  between  the  muscular  borders  of  part  of  the  abdominal 
contents,  with  the  resulting  symptoms  of  hernia.  If  properly  reduced,  the 
intestines  may  be  quite  easily  held  in  place  by  means  of  a  suitable  bandage, 
and  an  operation  subsequently  performed. 


VII.   MORBIDITY   IN   THE   PUERPERIUM. 

Since  the  general  adoption  of  asepsis  and  antisepsis  by  obstetricians  severe 
puerperal  morbidity  has  become  of  too  infrequent  occurrence  for  a  single  ob- 
server to  be  personally  familiar  with  all  its  phases.  As  a  natural  result,  the 
descriptions  of  these  affections  in  standard  works  contain  many  contradictions, 
and  it  is  by  no  means  easy  to  obtain  definite  ideas  as  to  the  various  manifesta- 
tions of  infection  and  intoxication  occurring  in  the  puerperium.  The  data 
accumulated  by  Lenhartz,  in  his  great  monograph  on  septic  affections,  are  by 
no  means  in  harmony  with  the  teaching  found  in  the  leading  text-books  on 
obstetrics.  I  have  therefore  tried  to  subject  the  entire  matter  of  puerperal 
morbidity  to  a  careful  analysis,  based  upon  the  latest  authoritative  data  and 
my  own  clinical  experience,  and  to  classify  and  describe  the  various  tvpes  of 
disease  in  such  a  way  as  to  eliminate  some  of  the  sources  of  contradiction  and 
confusion. 

Frequency  of  Morbidity  in  the  Puerperium.— The  usual  rough  test  between  a 
normal  and  a  pathological  puerperium  is  furnished  by  the  temperature.  If 
the  latter  is  over  100.4°  F.  (38°  C.)  in  the  axilla,  the  case  is  enumerated  under 
morbidity. 


712  PATHOLOGICAL  PUERPERWM. 

The  morbidity  of  the  Paris  cUnics  is  shown  by  the  following  figures  compiled  by  Budin: 
Charit6,  1891-1894,  10.7  per  cent.;  Maternite,  second  half  of  1895,  12.8  per  cent.;  1896, 
10.6  percent.;  1897,  10.6  per  cent.;  Tarnier's  clinic,  1898,  8.93  per  cent.;  1899,  12  per  cent. 
These  figures  make  the  average  morbidity  nearly  1 1  per  cent.  The  statistics  of  some  of  the 
leading  German  clinicians  are  as  follows:  Merman,  6  per  cent,  fever  of  over  100.4°  F-  (38°  C.) ; 
Leopold,  considerable  variation  from  year  to  year,  limits  from  8  to  20  per  cent,  approxi- 
mately, average  14.6  per  cent.;  von  Szabo,  19.75  P^^  cent.;  Zweifel,  17.4  per  cent.;  Hof- 
meier  and  Steffeck,  8.5  per  cent.;  Madlener,  18.6  per  cent.;  the  average  morbidity  in  these 
German  clinics  is  therefore  a  little  over  14  per  cent.  Ahlfeld,  who  has  collated  figures  from 
many  clinics,  finds  that  the  morbidity  varies  from  9  to  54  per  cent.  Such  fluctuation 
appears  to  show  that  differentiation  between  puerperal  and  other  fevers  is  very  difficult. 

Sellheim  believes  that  high  and  persistent  temperature  occurs  in  about 
2  per  cent,  to  4  per  cent,  of  institutional  cases.  In  an  analysis  of  2200  cases 
of  confinement  I  found  that  a  rise  of  temperature  to  100.4°  F.  (38°  C.)  or 
over  took  place  in  405  cases,  or  18.45  P^^  cent.  In  204  cases  the  fever  con- 
tinued but  a  few  hours,  there  being  but  a  single  elevation,  and  in  only  72  of 
the  405  cases  did  the  fever  last  for  more  than  three  days.  In  the  405  cases 
of  fever  the  rise  of  temperature  was: 

Due  to  constipation  in 259  cases,  or  63.95  P^^  cent. 

"      "   reflex  irritation  in    42       "        "    10.37     "       " 

"      "  complicating  disease  in 20       "       "     4.94    "       " 

"      "   neurotic  condition  in i        "       "      0.24    "       " 

79.50  per  cent. 

"      "   septic  infection  in 55       "       "    13.58  per  cent. 

"      "   no  assignable  cause  in 25       "       "      6.92    "       " 

20.50  per  cent. 

This  gives  a  morbidity  percentage  from  non-septic  conditions  of  79.50  per 
cent.;  from  sepsis,  of  13.58  percent.;  and  from  unknown  causes,  of  6.92  per  cent. 

Classification. — I  believe  this  subject  is  best  considered  under  three  main 
headings:  viz.,  {A)  Morbid  conditions  of  the  puerpera  which  antedate  labor.- 
(B)  Morbid  conditions  which  result  from  labor.  _(C)  Morbid  conditions  which 
originate  or  first  appear  in  the  puerperium.  While  it  is  customary  to  allude  to 
many  of  the  conditions  presenting  themselves  under  Divisions  A  and  B  as  pre- 
disposing causes  of  puerperal  morbidity,  a  little  reflection  will  show  that  they 
themselves  may  represent  morbidity  of  pronounced  types.  Conditions  under 
division  C  are  loosely  spoken  of  as  "  puerperal  infection,"  "puerperal  fever,"  "  pu- 
erperal sepsis,"  etc.  Once  regarded  as  manifestations  of  a  single  specific  dis- 
ease, they  are  now  known  to  comprise  a  variety  of  local  and  general  conditions. 


CLASSIFICATION  OF  PUERPERAL  MORBIDITY. 

(A)  MORBID  CONDITIONS  OF  THE  PUERPERIUH  WHICH  ANTEDATE  LABOR. 

Acuie:  I.  Acute  Toxemia  of  Pregnancy.  II.  Antepartum  Sapremia  or  Bacteriemia. 
III.  Chance  Infection  with  Acute  Specific  Diseases.  Chronic:  IV.  Chronic 
Toxemia  of  Pregnancy.  V.  Chronic  Toxemia,  etc,  not  Due  to  Pregnancy. 
VI.  Genital  and  Extragenital  Inflammations. 

(B)  MORBID  CONDITIONS  WHICH  RESULT  FROM  LABOR. 

General:  I.  Shock  and  Extreme  Fatigue  from  Dystocia.  II.  Acute  Anemia  from 
Hemorrhage.  Local:  III.  Incomplete  Labor.  Faulty  Contraction,  Evacua- 
tion, AND  Drainage.  IV.  Birth  Traumatisms.  V.  Changes  in  the  Locality 
and  Activity  of  the  Bacteria  of  the  Genital  and  Perigenital  Regions  In- 
duced BY  THE  Act  of  Labor  and  its  Management.  Migration.  Inoculation. 
Mobilization. 


MORBID  CONDITIONS  WHICH  ANTEDATE  LABOR.  713 

(C)  MORBID   CONDITIONS   WHICH   ORIGINATE   OR  FIRST  APPEAR  IN  THE 

PUERPERIUM. 

Primary,  Consecutive,  and  Metastatic  Focal  Infections. 
Primary  Focal  Injections. 
Genital:  I.   Puerperal  Ulcers.     II.  Endometritis  from  Saprophytes.     Putrid  Endo- 
metritis.    III.    Endometritis    from    Pyogenic    Bacteria.     Simple    Infectious 
Endometritis.     IV.  Endometritis    from    Mixed    Infection.     Composite  Endo- 
metritis.    Extragenital:  V.  Mastitis. 

Consecutive  Focal  Injections. 
Extension  by  Continuity.  VI.  Infection  of  Urinary  Tract.  VII.  Proctitis.  Vlll. 
Salpingitis.  Peritonitis.  Extension  by  Lymphatics:  IX.  Metritis.  X.  Para- 
metritis. XL  Peritonitis.  Circumscribed  or  Perimetritis.  General.  Ex- 
tension by  Veins:  XII.  Metrophlebitis.  Femoral  Phlebitis.  XIII.  Specific 
Diseases.     Gonorrhea.       Diphtheria.       Erysipelas.       Miscellaneous. 

Metastatic  Focal  Injections. 
Blood  States  or  General  Conditions. 
Simple. 
I.  Sapremia.     II.  Bacterial  Toxemia.     III.  Bacteriemia. 

Composite  Sepsis. 
IV.  Bacteriemia   with   Toxemia.     Septicemia.       Pyemia.        Septicopyemia.     V.  Sap- 
REMic  Sepsis.     (Gas  Sepsis.) 

Anomalies  oj  Temperature. 
VI.  Hyperthermia.     VII.  Fever.     VIII.  Hypothermia. 

(D)  CLINICAL  TYPES  OF  PUERPERAL  MORBIDITY. 

The  puerpera  inherits  from  the  pregnant  state  any  morbid  condition  from 
which  she  may  have  suffered  during  that  period,  whether  called  forth  by  preg- 
nancy or  not.  While  some  of  these  conditions,  especially  those  due  directly  to 
pregnancy,  have  a  natural  tendency  to  improve  after  delivery,  others  remain 
unaffected,  and  not  a  few  tend  to  become  worse;  while  conditions  absolutely 
dormant  are  sometimes  roused  into  being  for  the  first  time.  The  possible  legacy 
of  the  puerpera  must  therefore  always  be  borne  well  in  mind.  To  conditions  of 
this  character  must  be  added  the  shortcomings  and  accidents  of  labor  itself, 
and  the  various  readjustments  rendered  inevitable  by  the  transition  from  preg- 
nancy to  the  puerperium. 


(A)  MORBID  CONDITIONS  OF  THE  PUERPERIUM  WHICH  ANTEDATE 

LABOR. 

I.  Acute  Toxemia  of  Pregnancy. — This  condition  is  described  on  page  291. 

II.  Antepartum  Sapremia  or  Bacteriemia. — This  subject  includes  septic 
abortion  (pp.  355);  sapremia,  etc.,  from  dead  fetus  (pp.  272),  and  infection  which 
begins  in  the  course  of  an  arrested  labor,  which  is  only  an  anticipation  of 
postpartum  conditions  (pp.  570). 

III.  Chance  Infection  with  Acute  Specific  Diseases. — These  when  severe  tend 
ta  make  labor  premature  or  incomplete  and  thereby  favor  sepsis.  The  cause  of 
death  in  such  cases  is  often  sepsis  instead  of  typhoid  or  other  antecedent  in- 
fectious malady.     (See  Diseases  of  Pregnancy,  Part  III.) 

IV.  Chronic  or  Benign  Toxemia  of  Pregnancy. — (See  Toxemia  of  Pregnancv, 
Part  III.) 

V.  Chronic  Toxemias  not  Due  to  Pregnancy. — Here   belong  such  affections 


714  PATHOLOGICAL  PUERPERIUM. 

as  tuberculosis,  s^'philis,  diabetes,  uremia  pure  and  simple,  the  cardiac  cachexia, 
leukemia,  exophthalmic  goiter,  cancer,  etc.,  etc.,  all  of  which  are  considered 
elsewhere.  (See  Part  III.)  As  a  rule,  they  originate  before  conception,  but 
sometimes  do  not  manifest  themselves  until  afterward,  pregnancy  appearing  to 
hasten  their  development.  In  none  of  these  conditions  does  delivery  lead  to 
any  permanent  improvement,  and  in  many  it  rapidly  hastens  the  end;  so  that 
they  add  somewhat  to  the  mortality  of  the  puerperium.  Naturally  sepsis  is 
often  present  as  a  complication  or  is  an  actual  cause  of  death. 

VI.  Genital  and  Extragenital  Inflammations. — The  former  are  described  under 
diseases  of  the  deciduas  (pp.  191),  with  special  reference  to  gonorrheal  affec- 
tions. Ahlfeld  has  claimed  that  a  latent  gonorrheal  pelvic  peritonitis  may  be 
lighted  up  by  pregnancy.  Pelvic  abscesses,  pyosalpinx,  etc.,  from  any  cause, 
may  be  ruptured  during  labor.  Extragenital  pyogenic  processes  of  any  sort 
(otorrhea,  whitlow,  etc.)  may  be  the  remote  cause  of  a  septic  puerperium. 

(B)  MORBID  CONDITIONS  WHICH  RESULT  FROM  LABOR. 

I.  Shock  and  Extreme  Exhaustion  from  Dystocia  naturally  favor  infection. 
Fatigue  itself  i^  regarded  as  due  to  auto-intoxication. 

II.  Acute  Anemia  from  Hemorrhage. — This  occurs  after  high  degrees  of  post- 
partum hemorrhage  and  favors  infection.  The  blood  must  lose  much  of  its 
alexin  or  bactericidal  ferment.  As  shock  or  exhaustion  and  acute  anemia  are 
often  conjoined,  it  is  not  easy  to  comprehend  how  so  many  women  escape 
infection. 

III.  Incomplete  Labor. — This  term  is  used  to  denote  an  incomplete  third 
stage,  although  it  might  be  extended  to  include  retention  of  the  fetus  or  ovum. 
An  imperfect  third  stage  may  be  manifested  in  various  ways ;  and  while  due  in  part 
to  natural  shortcomings,  may  often  be  attributable  to  unskilful  management. 
It  comprises  the  following  subdivisions:  (i)  Incomplete  contraction  and  retrac- 
tion: This  condition  is  fully  considered  elsewhere  (page  568).  In  an  uncon- 
tracted  uterus  the  venous  sinuses  do  not  close  naturally  and  thrombi  form 
in  situ.  Thus,  hemorrhage  and  the  development  of  metrophlebitis,  embolism, 
and  air  embolism  are  favored.  (2)  Incomplete  evacuation:  This  is  considered  on 
page  574.  A  variety  of  tissues  may  remain  behind  after  incomplete  expulsion 
of  the  uterine  contents:  viz.,  portions  of  the  ovum  in  abortion,  portions  of  and 
even  the  entire  placenta,  fragments  of  membranes,  and  blood-clots.  This  dead 
tissue  forms  a  natural  breeding-place  for  saprophytes.  Decidual  fragments  and 
blood  are  hardly  to  be  regarded  as  foreign  bodies  and  escape  piecemeal  in  the 
lochial  discharge.  (3)  Incomplete  drainage:  Lochiometria.  In  some  cases  the 
normal  anteflexion  of  the  uterus  becomes  exaggerated  to  such  an  extent  that 
there  is  an  acute  angle  of  flexion  of  the  cervix  and  lower  uterine  segment  which 
suffices  to  prevent  the  exit  of  the  lochia.  The  uterus  is  large  and  soft  and  there 
are  well-marked  symptoms  of  sapremic  infection.  The  absence  of  lochial  dis- 
charge is  of  course  noted.  The  symptoms  are  at  once  relieved  by  the  manual 
replacement  of  the  uterus.  This  is  followed  by  a  copious  discharge  of  an  ill- 
smelling  fluid.  As  a  rule,  nothing  is  necessary,  except  irrigation.  Much  less 
commonly  the  cause  of  lochial  retention  is  retroflexion  of  the  puerperal  uterus. 
Lochiocolpos .  In  rare  instances  the  source  of  obstruction  is  in  the  vagina. 
This  rare  condition  is  known  as  "lochiocolpos."  Ahlfeld  reported  three  cases. 
In  one  the  cause  of  retention  was  an  intravaginal  hematoma,  and  in  another, 
a  too  thorough  repair  of  the  perineum ;  in  the  last  case  the  patient  had  had  a 
bad    laceration    of    the   perineum   and    her   thighs    had   been    tightly   bound 


MORBID  CONDITIONS   WHICH  RESULT  FROM   LABOR.        715 


Fig.  929. — Infection  of  the  Vulva.  Fig.  930. — Infection  of  the  Vulva  and 

Vagina. 


Fig.  931. — Infection  of  the  Vagina  and 
Endometrium. 


Fig.     932.  —  Extension     of     Infection 

THROUGH  THE  TuBES  TO  THE  OvARY. 


Fig.  933.  —  Extension  of  Infection 
through  the  lymphatics  from  the 
Uterine  Cavity  to  the  Parame- 
trium AND  Peritoneum. 


Fig.  934.  —  Extension  of  Infection 
through  the  Veins  from  the  Uter- 
ine Cavity  in    Puerperal  Pyemia. 


716  PATHOLOGICAL  PUERPERIUM. 

together.     The  treatment  consists  in  the  removal  of  the  cause  and  in  vaginal 
irrigation. 

IV.  Birth  Traumatisms. — These  have  been  considered  under  Pathological 
Labor  (Part  V).  They  include  rupture  of  the  uterus,  lacerations  of  the  cervix, 
vagina,  vulva,  and  perineum;  also  certain  more  remote  lesions,  like  peroneal 
paralysis.  These  injuries,  especially  those  of  the  cervix,  are  generally  recognized 
as  among  the  most  important  factors  in  puerperal  morbidity. 

V.  Changes  in  the  Bacteria  of  the  Genital  Region. — It  is  conceded  that  in 
the  great  majority  of  cases  the  uterus  and  its  contents  are  sterile  before 
delivery.  Exceptions  are  found  in  cases  of  endometritis  and  putrefaction  of 
the  dead  fetus.  It  was  formerly  believed  that  the  vagina  was  also  sterile  save 
in  cases  of  gonorrhea,  but  the  very  extensive  researches  of  Stolz,*  Hofmeier, 
and  Lenhartz  have  shown  that  a  healthy  vagina  may  harbor  pathogenic  germs 
which  have  evidently  migrated  from  the  vulva.  The  external  genitals  have 
always  been  recognized  as  swarming  with  germ-life.  During  and  after  delivery 
it  has  been  shown  that  in  a  large  number  of  instances  the  bacteria  which  are 
harbored  in  the  vagina  manage  to  reach  the  uterine  cavity,  where  under  favor- 
able circumstances  they  are  destroyed  by  the  uterine  secretions  before  they 
can  multiply. 

In  regard  to  the  nature  of  the  germ-life  concerned,  the  bacteiiology  of  the 
vulva,  vagina,  and  uterine  cavity  is  practically  the  same;  for  we  simply  have  an 
upward  migration  of  the  vulval  germs.  Hence,  whatever  are  comprised  under 
the  latter  head  may  be  found  in  the  upper  passages.  Ordinar}^  saproph^'tes 
and  pathogenic  cocci  may  occur  side  by  side ;  the  saprophytes  or  microbes 
sometimes  develop  pathogenic  qualities,  while  the  pathogenic  bacteria,  so  called, 
may  play  the  role  of  saprophytes.  Nothing  appears  to  be  gained  by  an  exten- 
sive classification  and  description  of  these  germs.  The  important  facts  to  bear 
in  mind  are  that  the  ordinary  pyogenic  cocci,  acting  temporarily  as  saprophytes 
or  scavengers,  may  become  virulent;  and  that  the  saprophytes  proper,  i.  e.,  the 
ordinary  bacteria  of  putrefaction,  may  multiply  prodigiously  if  there  is  any  dead 
matter  in  the  uterus,  and  set  up  conditions  to  bedescribed  later. 

The  bacteriology  of  the  puerperal  state  is  discussed  more  fully  under  the 
Etiology  of  Endometritis,  page  721. 


(C)    MORBID    CONDITIONS    WHICH    ORIGINATE    OR  FIRST    APPEAR 

IN  THE  PUERPERIUM. 

General  Remarks. — As  already  stated  these  conditions  had  best  be  divided 
into  focal  infections,  including  both  primitive  and  consecutive ;  and  blood-states 
or  general  conditions ,  including  toxaemias,  bacteriemias  (sepsis),  pyemia,  septi- 
copygemia;  and  anomalies  of  temperature,  such  as  true  fever,  simple  hyper- 
thermia, hypothermia,  etc.  This  classification  is  essentially  pathological  and 
must  be  accompanied  by  some  of  the  clinical  types  of  morbidity.  Thus 
focal  infection  may  or  may  not  be  associated  with  toxaemia  or  bacteriemia;  of 
the  blood-states,  toxemia  often  occurs  without  bacteriemia,  but  the  latter  is 
naturally  associated  with  toxemia,  and  may  pursue  its  course  with  the  picture 
of  toxffimia.  PyEemia  may  occur  by  itself  or  associated  with  bacteriemia  (sep- 
ticopyemia). While  toxaemia  and  bacteriemia  are  usually  associated  with 
hyperthermia,  simple  rise  of  temperature  may  be  due  to  nothing  more  than 

*  "  Studien  zur  Bakteriologie  des  Genitalkanales  in  der  Schwangerschaft  und  in  Wochen- 
bette,"  Wien,  1903. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM. 


v;.v^.'V 


Fig.  935. — Putrid  Endometritis  in  the 
Process  of  Healing,  i.  Necrotic  surface 
ofdecidua;  2.  granulation  wall;  3,  decidua; 
4,  muscle. — {Bumm.) 


Fig.  936. — Septic  or  Streptococcus 
Endometritis.  Endometritis  in 
Process  of  Repair.  i,  Necrosed 
decidual  surface  with  streptococci;  2, 
granulation  wall;  3,  muscle. — {Bumm.) 


Fig.  937. — Infection  of  Thrombi  at  Pla- 
cental Site,  i,  Surface  of  serotina;  2, 
septic  thrombus;  3,  granulation  wall;  4, 
muscle;    5,  thrombus;    6,  artery. — (Bumm.) 


Fig.  938. — Septic  Thrombophlebitis  op 
the  Uterus.  i,  Loosened  portion  of 
thrombus;  2,  vein  wall;  3,  vein  cavity;  4, 
thrombus. — (Bumm^.) 


Fig.  939. — Streptococci    in  the   Smallest  Lymph-spaces  between  the  Muscle-fibers 

OF  the  Uterine  Wall. — (Bumm.) 


718  PATHOLOGICAL  PUERPERIUM. 

mental  emotion  or  other  nervous  perturbation;    and  in  the  gravest  types  of 
infection  the  temperature  may  be  subnormal. 

PRIMARY,  CONSECUTIVE,  AND  METASTATIC  FOCAL  INFECTIONS. 

Focal  infections  may  be  divided  into  primary  and  consectUive.  The  former 
represent  a  direct  inoculation  of  the  germs  into  an  exposed  surface,  while  the 
latter  include  the  lesions  which  result  from  extension  of  the  primary  mischief, 
whether  by  continuity  of  surface  or  contiguity.  In  the  latter  case  extension 
occurs  by  the  lymphatics  or  the  blood-vessels.  When  bacteria  are  transported  by 
the  blood  or  lymph  streams  to  remote  regions,  causing  metastases,  we  may 
speak  of  the  latter  also  as  consecutive  lesions,  although  they  are  usually  treated 
as  mere  subsidiary  features  of  a  general  infection  of  the  entire  organism. 

Primary  Focal  Lesions. 

Generally  speaking,  these  result  from  a  direct  inoculation  of  germs  into 
traumatic  areas  resulting  from  labor  or  delivery.  These  comprise,  from  above 
downward,  the  exposed  placental  site  with  its  torn  venous  sinuses ;  laceration 
of  the  cervix  (always  present  in  primiparee) ;  and  laceration  of  the  vagina,  vulva, 
and  perineum.  These  lesions  may  vary  greatly  in  extent,  may  increase  in 
size,  may  coexist,  or  one  infected  area  may  involve  another.  But  the  primary 
lesions,  while  they  may  be  very  extensive,  are  not  diffuse.  We  refer  here  to 
ordinary  pyogenic  cocci  and  saprophytes.  Conditions  like  acute  gonorrhea, 
erysipelas,  and  diphtheria,  if  contracted  in  the  puerperium,  are  much  less  de- 
pendent on  traumatism,  and  are  consequently  able  to  cause  a  diffuse  process. 
But  such  conditions  are  so  rare  that  good  descriptions  of  them  are  not  readily 
found. 

Primary  lesions  may  be  discussed  independently,  although  they  are,  as  a 
rule,  accompanied  by  complications.  They  may  be  subdivided  into  (i)  puer- 
peral ulcers  and  (2)  endometritis. 

I.  Puerperal  Ulcers. — By  this  term  is  meant  the  infected  lacerations  of  the 
vulva,  vagina,  and  cervix.  These  traumatisms  have  a  natural  tendency  to 
repair,  but  if  the  vaginal  secretions  or  lochia  contain  virulent  pyogenic  bacteria, 
healing  does  not  occur;  and  if  the  lacerations  have  been  closed  by  sutures,  the 
latter  cut  through.  Infection  is  indicated  by  the  formation  of  a  diphtheroid  false 
membrane,  due  to  the  irritating  properties  of  the  bacterial  toxins.  Even  after 
infection  there  is  still  a  decided  tendency  to  ultimate  recovery,  for  the  formation 
of  a  defensive  wall  of  leucocytes  and  proliferation  tends  to  prevent  the  penetra- 
tion of  the  bacteria  and  the  false  membrane  is  exfoliated.  It  is  important  to 
know  the  clinical  significance  of  these  ulcers.  In  the  first  place,  they  are 
frequently  associated  with  septic  endometritis,  in  which  case  they  represent 
only  a  minor  complication.  If  the  cervix  if  found  free  from  such  ulcers,  there 
is  little  likelihood  of  an  intrauterine  lesion.  Uncomplicated  puerperal  ulcers 
are  generally  spoken  of  as  relatively  harmless,  but  Lenhartz  finds  that  small 
external  ulcers  may  frequently  cause  sepsis  of  a  severe  character;  the  amount 
of  toxins  formed  in  such  cases  must  be  small,  so  that  the  sepsis  produced  is  of 
the  purest  type. 

Endometritis. — Puerperal  endometritis  comprises  several  varieties.  In  re- 
spect to  cause,  we  have  putrid,  pyogenic,  and  mixed  forms,  according  as  the 
pathogenic  microorganisms  are  infective,  or  saprophytic,  or  both  combined.  In 
respect  to  degree,  we  have  simple,  benign,  or  localized  forms,  in  which  the  forma- 
tion of  the  leucocyte  barrier  and  the  occlusion  of  the  placental  sinuses  respec- 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     719 


lively  protect  the  contiguous  structures  and  organism  at  large  from  the  exten- 
sion of  the  disease;  the  constitutional  reaction  being  akin  to  simple  surgical 
fever  or  simple  toxemia,  and  malignant  forms,  in  which  the  microorganisms 
invade  the  periuterine  tissues  by  the  lymphatic  route  or  penetrate  into  the 
uterine  veins,  producing  in  many  cases  such  formidable  complications  as  peri- 
tonitis and  pyemia. 

II.  Simple  Putrid  or  Saprophytic  Endometritis. — Introduction. — In  every  nor- 
mal puerperium  there  is  a  slight  degree  of  sloughing  of  the  endometrium  in- 
cidental to  regeneration  of  that  structure.  Some  little  time  is  required  for  the 
formation  of  the  regenerative  leucocyte  layer  and  the  lochial  secretion  with  its 
bactericidal  function.  During  the  interval  which  elapses  between  evacuation 
and  retraction  of  the  uterus 
and  the  establishment  of 
these  defenses,  saprophytes 
undoubtedly  enter  the  uterus 
from  the  vagina  in  a  large 
percentage  of  cases  and  mul- 
tiply to  a  certain  extent. 
These  comprise  not  only  a 
number  of  species  of  harmless 
"carrion-eaters,"  which  have 
never  been  recognized  as 
pathogenic,  and  certain  forms 
of  saprophytes  which  are  sus- 
pected of  pathogenic  qualities 
under  certain  conditions,  but 
also  highly  virulent  germs 
which  are  capable  of  behaving 
as  saprophytes  in  particular 
cases,  including  the  strepto- 
coccus pyogenes.  We  do  not 
know  whether  these  sapro- 
phytes should  be  regarded  as 
physiological  scavengers  or  as 
meddlesome  intruders.  Since 
the  discovery  of  the  existence 
and  properties  of  intracellular 
ferments,  we  recognize  the 
fact  that  bacteria  are  not  es- 
sential to  the  breaking  up  of 
cast-off  protein  matter.  After 
the  establishment  of  the  lochial  discharge,  the  tendency  of  the  uterus  is  to  purify 
itself  of  germ-life.  Bearing  in  mind  this  fact,  in  association  with  the  treacherous 
character  of  bacteria,  it  is  probably  best  to  regard  all  germ-life  in  the  puerperal 
uterus  as  something  foreign  and  undesirable ;  but  whether  accomplished  by  tissue- 
ferments,  saprophytes  or  both  conjoined,  there  is  no  doubt  that  the  refuse  proteid 
matter  of  the  regenerating  endometrium,  in  breaking  up  into  simpler  and  more 
soluble  and  diffusible  cleavage-products,  is  able  to  cause  a  very  mild  and  tran- 
sitory autointoxication,  recognizable  by  the  thermometer  in  a  half — perhaps  even 
more — of  all  puerpera.  This  condition,  commonly  known  as  "one-day  fever,"  is 
described  under  clinical  types.  Endometritis  as  such  does  not  coexist — aside  from 
the  normal  regenerative  changes  in  the  endometrium  which  hardly  merit  such  a 


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FOLLOWED  BY  THE  USE  OF  ErGOT. 


720 


PATHOLOGICAL  PUERPERIUM. 


name.  Bumm,  who  believes  that  in  a  normal  puerperium  the  -uterine  cavity  is 
sterile  from  first  to  last,  asserts  that  the  normal  lochia  are  always  sterile  until 
they  reach  the  vagina,  when  they  quickly  putrefy.  Such  a  condition  of  affairs 
may  frequently  occur,  but  is  not  the  rule. 

Since  saprophytes  multiply  in  proportion  to  the  amount  of  dead  material 
present  in  the  uterus,  it  is  evident  that  the  local  and  general  reaction  must 
depend  largely  upon  the  latter  factor.  Even  if  these  germs  are  essentially 
foreign  to  the  uterine  cavity,  the  presence  of  a  certain  amount  of  putrefaction 
of  residual  shreds  of  decidua,  blood  coagula,  etc.,  during  the  establishment  of 
the  lochia  is  not  necessarily  a  pathological  process,  and  is  not  regarded  as  con- 
stituting an  indication  for  intervention.     This  condition,  which  may  be  termed 

simple  putrescence  of  the 
lochia,  will  be  alluded  to 
again  under  clinical  types. 
The  process  is  not  sufficiently 
active  to  produce  endometri- 
tis or  toxemia,  or  to  interfere 
with  normal  regeneration. 
It  is  otherwise  when  there  is 
considerable  retained  matter, 
either  from  imperfect  evacu- 
ation of  the  placenta  or  mem- 
branes, or  defective  drainage 
(lochiometra).  A  double  dan- 
ger is  present  when  the  uterus 
is  not  completely  emptied, 
for  normal  contraction  and 
retraction  cannot  occur.  The 
placental  sinuses,  instead  of 
closing  by  adhesion  of  their 
walls,  become  plugged  by 
thrombi,  and  the  process  of 
normal  regeneration  with 
formation  of  -a  bactericidal 
lochia,  is  somewhat  dis- 
turbed. In  retention  of  the 
entire  placenta,  of  the  entire 
ovum  or  fetus,  in  gangrene  of 
the  uterus  from  pressure — in 
general  wherever  there  is  an 
opportunity  for  extensive 
putrefaction,  one  of  two  things  must  happen  if  the  uterus  is  not  promptly  evacu- 
ated: viz.,  putrid  endometritis  with  high  degrees  of  sapremia  develops  as  an  un- 
complicated condition,  or  from  virulent  and  infectious  germs  already  present  in 
the  uterus  or  conveyed  there  by  attempts  at  evacuating  the  uterus  becoming 
roused  to  activity,  a  mixed  endometritis,  to  be  considered  later,  is  set  up. 

Definition. — Putrid  or  saprophytic  endometritis  is  an  endometritis  set  up 
by  the  contact  of  the  irritating  secretions  of  the  saprophytic  bacteria  together 
with  some  of  the  products  of  the  putrefaction  of  the  dead  proteid  matter 
retained  within  the  uterus;  in  other  words,  the  irritant  material  is  composed  of 
bacterial  toxalbumoses  and  ptomaines.  It  is  never,  perhaps,  a  purely  local 
affair,  being  accompanied  by  the  results  of  absorption  of  the  irritant  material 


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Fig.  941. — Fever  due  to  Mild  Intra-partum  Infec- 
tion FOLLOWING  Version  on  a  Macerated  Fetus. 
Maternal  Syphilis. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     721 

by  the  lymphatics  and  veins,  expressed  clinically  by  the  phenomena  of  sap- 
remia  {q.  v.)  (p.;  741). 

Pathology  and  Pathogeny. — The  irritant  substances  in  question  set  up  an 
endometritis  which  has  a  more  or  less  constant  tendency  to  end  in  necrosis  of 
varying  degrees.  If  the  uterus  is  evacuated  within  a  reasonable  interval,  necro- 
sis of  the  endometrium  does  not  result ;  but  if  the  condition  is  left  to  itself,  the 
saprophytes  accumulate  in  such  numbers  and  activity  that  the  endometrium, 
already  in  the  act  of  throwing  off  dead  material,  becomes  involved  in  the  ne- 
crosis. If  the  degree  of  the  latter  is  slight,  we  have  only  an  intensification  of 
the  normal  exfoliation  of  the  mucosa;  and,  with  cause  removed,  the  formation 
of  the  leucocyte  layer  and  the  bactericidal  lochia,  albeit  somewhat  delayed,  pre- 
vails in  the  end  over  the  pathogenic  factors.  If  the  circumstances  are  less 
favorable,  the  degree  of  necrosis  may  be  sufficient  to  interfere  utterly  with  normal 
regeneration  and  purification  of  the  endometrium.  Mixed  infection  then  devel- 
ops, or  in  certain  cases  the  putrid  endometritis  may  acquire  such  severity  that 
the  patient  may  die  of  intense  sapremia,  or  even  in  rare  cases  of  a  generali- 
zation of  the  saprophytes  throughout  the  system  (gas-sepsis).  The  latter  ter- 
mination must  be  of  very  rare  occurrence,  and  its  existence  is  difficult  to  demon- 
strate. In  the  majority  of  such  cases  mixed  infection  is  present;  or  the 
saprophytes  do  not  become  generalized  until  the  patient  is  dead  or  at  least  mori- 
bund.    (Figs.  935  and  936.) 

Symptoms. — In  putrid  endometritis,  the  uterus  is  not  properly  contracted, 
and  more  or  less  tenderness  is  present.  The  lochia  are  very  fetid,  and  contain 
much  necrotic  debris  and  are  frothy  from  admixture  of  gas-bubbles.  Pus  is  not 
present.  An  examination  of  the  secretions  shows  the  presence  of  saprophytes. 
The  lochia  may  be  "suppressed";  this  is  not  due  to  a  drying  up  of  the  secreting 
surface,  but  to  some  form  of  mechanical  obstruction — either  anteflexion  of  the 
uterus  or  plugging  of  the  os  with  necrotic  tissue.  When  the  obstruction  is  re- 
moved, there  is  a  profuse  escape  of  pent-up  lochia  having  the  characters  already 
described.  Putrid  endometritis  is  always  accompanied  by  sapremia  which  varies 
in  degree  with  the  amount  of  putrefaction.  Pure  sapremia,  which  is  always 
due  to  this  condition,  is  discussed  separately  on  page  741. 

Diagnosis. — The  various  diagnostic  points  are  included  in  the  preceding  para- 
graph.    An  absolute  diagnosis  must  rest  upon  the  bacteriology. 

Prognosis. — As  long  as  the  condition  is  simply  a  putrid  endometritis,  the 
prognosis  depends  largely  upon  the  promptness  and  completeness  with  which 
the  uterus  is  evacuated.  But  even  after  existing  for  a  number  of  days,  emptying 
of  the  uterus  may  be  followed  by  recovery.  Much  also  depends  upon  the  rapidity 
of  absorption  of  the  toxins.  The  sapremia  may  be  so  acute  that  the  patient's 
vital  organs  are  quickly  overwhelmed.  On  the  other  hand,  the  steady  and  pro- 
tracted absorption  of  toxins  in  an  unrelieved  case  naturally  tends  to  cause 
death  by  exhaustion. 

Treatment. — See  page  726. 

III.  Simple  Pyogenic  or  Infectious  Endometritis. — Definition. — A  puerperal 
focal  lesion  due  to  the  pathogenic  action  of  infectious  microorganisms  upon  the 
endometrium  which  is  in  course  of  regeneration. 

Etiology  and  Pathogeny. — The  various  predisposing  and  exciting  causes  of 
pyogenic  endometritis  have  been  outlined  in  the  general  sections  on  the  mor- 
bidity of  the  puerperium.  We  do  not  find  here  the  unevacuated  or  undrained 
uterus  which  is  a  necessary  factor  in  the  production  of  the  putrid  and  mixed 
forms  of  endometritis.  Other  factors  come  into  play,  such  as  the  ascent  into 
the  uterus,  during  or  after  delivery,  of  infectious  germs  which  have  in  some 
46 


722 


PA THOLOGICAL  P  UERPERI UM . 


manner  found  their  way  into  the  vagina;  or  the  direct  inoculation  of  the  uterine 
cavity  by  the  surgeon's  instruments  or  hands  in  connection  with  the  artificial 
termination  of  labor.  Epidemic  prevalence  of  the  disease  is  a  prominent  fac- 
tor. In  certain  cases  the  endometrium  is  infected  from  birth  wounds  of  the 
lower  genitals.  It  is  often  impossible  to  determine  how  infection  takes  place, 
so  that  we  are  forced  to  think  of  a  preexisting  endometritis  or  a  hematogenous 
infection.  Finally,  predisposition  plays  an  important  part.  Whatever  greatly 
lowers  the  resisting  powers  of  the  puerpera  during  the  early  days  of  the  puerpe- 
rium,  before  the  establishment  of  the  natural  defenses — especially  hemorrhages, 
eclampsia,  preexistent  toxic  states,  the  shock  of  protracted  labor,  etc.,  etc., 
all  render  it  possible  for  pyogenic  cocci,  which  ordinarily  would  enter  the  uterus 
as  saprophytes,  to  become  pathogenic.      In  many  of   these  cases  the  uterus, 

which  has  been  completely 
evacuated,  is  nevertheless 
unable  to  contract  properly. 
The  placental  sinuses  remain 
patulous,  or  are  imperfectly 
closed  by  thrombi;  and  it  is 
this  locality  which  is  usually 
first  attacked  by  the  pyo- 
genic cocci,  many  cases  of 
simple  infectious  endometri- 
tis remaining  localized  in  this 
area.     (Figs.  937  and  938.) 

The  bacteria  which  cause 
this  form  of  endometritis 
consist  of  the  common  pyo- 
genic microorganisms,  chiefly 
the  streptococcus  pyogenes, 
but  occasionally  the  staphy- 
lococcus aureus  and  albus, 
and  more  rarely  of  other  pyo- 
genic bacteria.  A  mixture  of 
infection  is  not  uncommon. 

The  pathogeny  of  infec- 
tious endometritis  differs 
notably  from  that  of  the  pu- 
trid form.  In  the  latter,  as 
already  stated,  the  bacteria 
do  not  attack  the  living 
tissues,  and  the  inflammation  is  produced  entirely  by  the  corrosive  action  of  the 
bacterial  secretions  and  decomposition  products  of  the  dead  tissue.  In  pyogenic 
endometritis,  on  the  other  hand,  the  bacteria  attack  the  living  tissues,  and  through 
multiplying  therein,  produce  a  necrotic  layer  which  greatly  resembles  the  false 
membrane  of  true  diphtheria,  and  which  may  vary  greatly  in  thickness  and  extent. 
In  its  lightest  form  it  has  been  compared  to  a  mere  "haziness,"  while  in  the  higher 
degrees  the  necrotic  endometrium  may  come  away  in  large  shreds.  When  dead 
tissue  thus  appears  in  the  uterus  to  this  extent,  certain  complications  may  arise. 
Thus  the  os  may  be  obstructed  temporarily,  and  the  lochia  pent  up.  Again  the 
presence  of  the  dead  tissue  favors  the  development  of  an  associated  putrid  endo- 
metritis. 

Symptoms;  Course. — If  the  endometrium  is  attacked  by  pyogenic  cocci  during 


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-Fever  due  to  Mild  Streptococcus  Infec- 
tion. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     723 

the  period  of  regeneration,  a  struggle  for  the  mastery  ensues  between  the  micro- 
organisms and  the  defensive  forces.  If  the  latter  prevail,  the  leucocyte  barrier 
increases  in  extent,  pus  is  formed  in  increasing  amounts,  and  through  the 
mechanical  action  of  this  fluid,  the  necrotic  tissue  is  broken  up  and  washed 
away.  The  lochia  acquires  bactericidal  properties,  and  the  uterine  cavity  tends 
to  become  sterile.  Under  these  circumstances  the  disease  runs  a  benign  course. 
The  uterus  exhibits  some  tenderness,  and  an  ordinary  surgical  fever  is  present, 
caused  by  absorption  of  the  toxins  secreted  by  the  bacteria.  The  lochia  are 
purulent  and  entirely  devoid  of  odor  and  the  microscope  reveals  the  presence 
of  one  or  more  forms  of  pyogenic  cocci. 

If,  on  the  other  hand,  the  disease-germs  prevail  over  the  vital  forces,  malignant 
endometritis  results.  Two  very  different  types  of  the  latter  are  recognized  and 
the  two  may  be  combined  to  form  a  third.  Since  infection  usually  begins  at 
the  placental  site,  much  depends  upon  the  condition  of  the  latter  at  the  time. 
If  the  uterus  is  well  retracted  and  the  sinuses  closed,  the  defense  at  this  point 
is  effective.  If  the  sinuses  are  simply  plugged  with  aseptic  thrombi,  virulent 
germs  may  infect  the  latter  directly,  or  may  first  penetrate  between  the  sinuses, 
and  eventually  through  the  walls  of  the  latter  from  without.  This  type  of 
malignant  endometritis  which  passes  directly  into  pyemia,  is  manifested  usually 
by  a  succession  of  chills  denoting  the  sudden  entrance  into  the  circulation  of 
a  large  amount  of  toxic  material.  In  the  other  type  of  malignancy  we  may 
suppose  that  the  placental  sinuses  escape,  but  that  the  endometrium  is  the  seat 
of  extensive  pyogenic  infection ;  the  virulence  or  numbers  of  the  germs  enable 
them  to  penetrate  the  leucocyte  barrier  and  enter  the  subjacent  lymph-spaces 
in  such  numbers  and  activity  as  to  infect  the  parametrium  or  perimetrium  or 
even  the  blood  itself.  Clinically  this  type  of  endometritis  would  be  expressed 
by  evidences  of  pelvic  inflammation  superadded  to  uterine  pain  and  tenderness. 
As  is  readily  apparent  from  what  has  been  said,  the  moment  an  endometritis 
is  to  be  classed  as  malignant,  the  infection  has  already  extended  beyond  the 
uterus — either  along  the  uterine  veins  or  into  the  pelvis.  These  two  types  of 
malignant  endometritis,  viz.,  the  venous  and  lymphatic,  may  be  conjoined,  and 
we  then  have  a  special  blood-state  termed  septicopyemia  (q.  v.). 

Diagnosis. — In  the  milder  forms  of  pyogenic  endometritis  there  may  be  but 
little  constitutional  disturbance — nothing  beyond  a  slight  resorption-fever — and 
local  symptoms  may  likewise  be  absent.  Under  such  circumstances  diagnosis 
can  be  made  only  by  the  purulence  of  the  lochia,  and  the  presence  therein  of 
the  pyogenic  cocci  in  large  quantities.  In  higher  degrees  we  find  tenderness " 
and  the  toxemic  state  more  highly  developed,  this  accentuation,  as  in  other 
suppurating  cavities,  being  sometimes  dependent  upon  imperfect  drainage.  The 
evidences  of  malignancy  have  already  been  enumerated.  Since  streptococci 
have  been  known  to  enter  the  circulation  and  remain  therein  in  a  latent  state 
for  days,  we  should  examine  the  blood  in  all  cases  of  persistent  elevation  of 
temperature,  even  in  the  absence  of  symptoms  of  blood  infection,  or  extension 
of  the  morbid  process  beyond  the  uterus. 

Prognosis. — As  long  as  the  uterus  is  movable,  drainage  maintained,  blood 
examinations  negative,  and  the  march  of  the  temperature  in  accord  with  simple 
localized  suppuration,  the  prognosis  is  good,  the  condition  hardly  calling  for 
active  treatment.  As  soon  as  there  is  evidence  of  extension  of  the  process  by 
the  veins  or  lymphatics,  the  question  is  no  longer  one  of  endometritis,  for  the 
latter,  per  se,  could  hardly  endanger  life.  In  those  extreme  cases  in  which  the 
entire  uterus  is  inflamed  and  softened,  extension  of  the  disease  has  already 
occurred,  death  really  taking  place  from  pyemia  or  peritonitis. 


724 


PATHOLOGICAL  PUERPERIUM. 


Treatment. — See  page  726. 

IV.  Endometritis  from  Mixed  Infection  ;  Composite  Endometritis. — AVhile  this 
affection  is  of  frequent  occurrence  and  is  naturally  grave  in  character,  its  charac- 
teristics have  been  so  thoroughly  discussed  under  the  individual  types  of  en- 
dometritis that  but  little  more  need  be  given  here  than  a  recapitulation. 


mlMmMrVerL  ^■ 


SuspmsonjUnmCofOiwy  


Fig.  943. — Puerperal  Uterus,  Three  Hours  Post  Partum,  the  Site  of  Streptococcus 

Endometritis. —  {Sellheim.) 

Whenever  an  unevacuated  uterus  leads  to  the  development  of  putrid  endome- 
tritis, a  pyogenic  infection  is  readily  grafted  upon  the  initial  trouble.  If  strepto- 
cocci are  present  at  the  outset,  as  "acting  saprophytes,"  they  may  be  roused 


PkKxntaUite 
bladder  ^ 

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Introitus  Vc^?tae   /  ■/  v^v  /^ 

£ji;t.03.  -Ts-ff^  V. 


PostCerv-^P- 


Perineum 


Anus      /^ 
/nt5p/ii7iaer 
£xt.3p/nn€terAni. 

/'ouc/io/'Dou^las  ~ 

Fig.  944. — Sagittal  Section  of  a  Puerperal  Uterus  Three  Hours  Post  Partum  with 
Streptococcus  Endometritis.     Same  case  as  Fig.  943. — {Sellheim.) 


to  the  virulent  or  infectious  state  through  rapid  multiplication  in  the  presence 
of  the  necrotic  tissue.  From  another  point  of  view  the  presence  of  a  putrid 
endometritis  causes  a  lowering  of  the  local  resisting  power,  an   impairment  of 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     725 

the  regenerative  faculty  of  the  endometrium,  and  a  depreciation  of  the  bacteri- 
cidal power  of  the  lochia.  Under  these  circumstances  streptococci,  however 
introduced  into  the  uterus,  are  able  to  flourish  and  exert  their  pernicious 
influence. 

We  have  already  seen  that  putrid  endometritis  need  not  always  be  the 
primary  lesion;  for  the  diphtheroid  membrane  which  results  from  pyogenic 
infection  of  the  endometrium  constitutes  necrotic  tissue  upon  which  saprophytes 
are  able  to  feed  and  increase  in  numbers.  According  to  Bumm,  the  pyogenic 
cocci  usually  take  precedence  in  associate  infection;  they  cause  necrosis  of  the 


Fig.  945. — LocHiAL  Secre- 
tion OF  Putrid  Endome- 
tritis.— (Bumm.) 


Fig.  946. — LocHiAL  Secre- 
tion OF  Septic  Endome- 
tritis.— (Bumm.) 


Fig.  947. — LocHiAL  Secre- 
tion OF  Gonorrheal  En- 
dometritis.—  (Bumm.) 


endometrium,  and  thereby  enable  the  saprophytes  to  obtain  a  foothold.  Gener- 
ally speaking,  the  conditions  are  such  that  the  development  of  mixed  endometritis 
is  naturally  favored.  Pure  examples  of  saprophytic  or  pyogenic  infection  are 
doubtless  less  frequent  than  is  usually  taught. 

Symptoms;  Course. — In  the  majority  of  cases  composite  endometritis  doubt- 
less begins  with  the  putrid  form;  i.  e.,  with  an  unevacuated  uterus.  If  the 
latter  is  emptied,  the  expected  defervescence  does  not  occur,  and  it  becomes 
apparent  that  the  composite  endometritis  has  been  transformed  into  the  simple 
pyogenic  form.     The  prognosis  of  the  latter  is,  however,  much  graver  than  is 


Fig.  948. 


-Glass  Cannula  for  Obtaining  Lochial  Secretion  from  the  Uterus. 
(i  natural  size.) 


the  case  when  the  pyogenic  affection  is  primary;  and  it  is  very  evident  that  the 
associate  affection  has  so  crippled  the  defenses  of  the  organism  that  the  endome- 
tritis is  very  likely  to  become  malignant. 

As  already  implied,  unless  the  putrid  endometritis  is  of  such  intensity  or 
duration  as  to  necrotize  the  endometrium, thorough  evacuation  of  the  uterus  will 
transform  the  composite  into  the  simple  pyogenic  form — since  the  saprophytes 
are  thereby  deprived  of  nutriment.  Under  unusual  circumstances,  such  as 
retention  of  a  large  amount  of  fetal  tissue  for  a  protracted  period,  or  pressure- 
gangrene  of  the  uterus,  the  putrefaction  of  the  latter  is  so  extensive  that  removal 


726 


PATHOLOGICAL  PUERPERIUM. 


or  disinfection  of  the  necrotic  tissue  is  impossible.  If  after  repeated  douching 
of  the  uterus  the  lochia  continue  fetid,  it  is  evidence  that  the  endometrium  has 
been  extensively  involved  in  the  putrefactive  process.  Such  cases  naturally 
remain  composite  to  the  end,  and  are  comparable  with  neglected  cases  in  which, 
for  one  reason  or  another,  there  has  been  no  attempt  to  evacuate  the  uterus. 

When  under  such  circumstances  the  affection  remains  composite  to  the  end, 
the  condition  known  as  sapremic  sepsis  develops;  or,  in  other  words,  the  blood 
changes  which  tend  to  accompany  each  disease  singly,  are  found  side  by  side. 


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and  drained.  Temperature  on  the  twenty-seventh  day  of  the  puerperium  normal  and 
pulse  seventy-four. 


Moreover,  in  the  very  highest  type  of  puerperal  morbidity,  the  saprophytes 
may  enter  the  circulation  before  death  and  cause  the  so-called  gas-sepsis  (g.  v.). 
Uncomplicated  sapremia  (from  putrid  endometritis)  and  uncomplicated  sepsis 
are  without  doubt  responsible  for  many  deaths  among  puerperae ;  yet  it  is  very 
likely  that  in  untreated  cases  mixture  of  infection  results  sooner  or  later. 

Diagnosis. — The  lochia  afford  the  sole  means  for  a  rational  diagnosis.  If 
this  discharge  is  both  fetid  and  purulent,  containing  in  addition  gas-bubbles; 
and  if  a  microscopic  examination  reveals  both  saprophytes  and  pyogenic  cocci 
in  large  numbers,  the  diagnosis  is  assured. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     727 


Prognosis. — If  defervescence  occurs  within  a  reasonable  period  after  the 
uterus  has  been  emptied  and  irrigated,  the  prognosis  is  good.  If  the  fever  does 
not  disappear,  or  if  it  returns  after  a  short  fever- free  interval,  it  is  probable 
that  the  streptococci  have  passed  beyond  the  confines  of  the  endometrium. 

V.  Mastitis. — (See  Diseases  of  the  Breast,  Part  VII.) 

Primary  focal  lesions  in  the  genital  canal  which  result  from  specific  infectious 
processes,  as  gonorrhea,  diphtheria,  and  erysipelas,  receive  separate  attention  on 
page  737. 

I  have  already  insisted  that  malignant  puerperal  endometritis  implies  some 
form  of  secondary  extension 
of  the  primary  mischief;  in 
other  words,  it  is  not  merely 
the  going  from  bad  to  worse 
of  the  uterine  lesion.  I  shall 
first  enumerate  the  results  of 
extension  by  continuity  of 
surface,  which  are  relatively 
benign  in  comparison  with 
the  conditions  which  result 
from  extension  along  the 
vessels.  From  puerperal  ul- 
ceration near  the  urethra,  the 
urinary  tract  may  become  in- 
volved; from  ulceration  of  a 
complete  perineal  tear,  the 
rectum  may  be  involved,  at 
least  in  theory.  Finally,  in 
pyogenic  endometritis  the 
tubes  are  readily  involved  by 
continuity.  These  conditions 
are  now  briefly  described. 

Consecutive  Focal  Infec- 
tion. 

Consecutive  Lesions  from  Ex- 
tension by  Continuity. 

VI.  Puerperal  Infection  of 
the  Urinary  Tract  {Pyogenic 
Urethritis,  Cystitis,  Pyelitis, 
Pyelonephritis).  —  Naturally 
these  conditions  do  not  differ 
materially  from  ordinary 
urinary    infection    from   the 

use  of  septic  catheters.  Indeed,  this  very  accident  may  occur  in  the  puerperium, 
and  hence  catheterization  is  to  be  avoided  as  far  as  possible  and  done  only  under 
the  strictest  asepsis  (see  Management  of  Puerperium). 

VII.  Puerperal  Proctitis. — This  condition,  which  is  extremely  rare,  and  might 
also  occur  from  some  accident,  as  from  a  septic  syringe,  represents  an  inoculation 
of  some  raw  surface,  and  is  in  fact  a  puerperal  ulcer  of  the  rectum,  having  the 
same  symptoms,  diagnosis,  and  treatment.  Puerperal  rectal  gonorrhea  may 
occur. 


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Fig.  950. — Fever  due  to  Gonorrheal  Cystitis  in 
THE  Puerperium,  the  Gonococcus  being  found 
IN  the  Pus  from  the  Urethra.  Irrigation  of 
the  bladder  practised  and  urotropin  administered. 


728  PATHOLOGICAL  PUERPERIUM. 

VIII.  Puerperal  Salpingitis. — This  is  stated  to  be  a  somewhat  infrequent  con- 
secutive lesion  and  must  be  distinguished  from  salpingitis  which  occurs  secondarily 
to  peritonitis.  Uncomplicated  salpingitis  from  direct  extension  of  pyogenic  endo- 
metritis has  the  characters  of  abscess-formation,  supervening  with  a  rigor,  a  fever 
which  may  reach  104°,  and  in  some  cases  severe  pain.  Physical  examination  will 
reveal  a  tumor  which  when  developed  is  of  a  sausage  shape. 

Consecutive    Lesions    Due    to    Extension    Along    the    Uterine    Vessels. 

We  know  that  evefi  in  relatively  mild  cases  of  endometritis,  streptococci  are 
able  to  break  through  the  leucocyte  barrier  into  the  uterine  lymph  spaces, 
although  they  do  not  necessarily  set  up  metritis  or  other  consecutive  lesions. 
Generally  speaking,  whenever  the  pyogenic  cocci  pass  this  barrier,  we  should 
no  longer  speak  of  endometritis,  for  with  these  germs  once  in  the  lymph  spaces 
there  is  nothing  to  prevent  the  further  extension  of  infection  which  may  involve 
the  uterus,  parametrium,  perimetrium,  or  ovary;  in  fact  all  the  accidents  of 
extension  result  here  save  those  which  arise  from  direct  extension  along  the 
veins  at  the  placental  site.  We  therefore  differentiate  between  lymphatic  and 
venous  septicemia,  the  latter  being  known  as  pyemia. 

Consecutive  Lesions  from  Lymphatic  Extension. 

These  comprise  metritis,  pelvic  lymphangitis,  parametritis,  oophoritis,  peri- 
metritis (or  benign  peritonitis),  and  malignant  or  general  peritonitis.  The  par- 
ticipation of  the  peritoneum  may  be  secondary  to  metritis  or  parametritis. 
With  any  of  the  accidents  we  see  always  the  occurrence  of  toxemia  with  or 
without  bacteriemia.  It  should  be  stated,  also,  that  a  low  form  of  peritonitis 
may  follow  simple  putrid  endometritis  and  also  gonorrhea.  On  the  other  hand, 
sepsis  may  be  so  sudden  and  intense  in  development  that  dissolution  of  the 
blood  may  outstrip  the  formation  of  consecutive  foci.  Under  such  circumstances 
there  would  probably  be  found  at  autopsy  some  such  coincidence  as  antepartum 
sepsis,  with  pressure-gangrene  of  some  part  of  the  uterus  and  evidences  of 
beginning  peritonitis.  From  the  blood  and  some  of  the  viscera  we  may  obtain 
pyogenic  cocci  in  association  with  putrefactive  bacteria. 

The  consecutive  lesions  enumerated  above  will  now  be  discussed  individually. 

IX.  Metritis. — This  term  is  practically  synonymous  with  malignant  endome- 
tritis. As  the  endometrium  and  muscularis  are  continuous  the  latter  is  invariably 
infected  whenever  the  leucocyte  barrier  does  not  withstand  the  attacks  of  the 
infecting  organisms.  The  streptococci  usually  multiply  along  the  coarser 
lymphatics  of  the  uterus,  and  may  not  pass  through  the  vascular  walls.  In  this 
case  the  parametrium  may  be  the  first  structure  to  feel  the  brunt  of  the  attack 
or  the  peritoneum  may  be  selected.  In  other  cases  the  streptococci  multiply 
throughout  the  finer  lymphatics  as  well,  and  also  pass  through  the  vascular 
walls,  setting  up  intramuscular  abscesses,  and  sometimes  lead  to  necrosis  of 
entire  portions  of  the  musculature  (metritis  dissecans).  This  so-called  lymphatic 
infection  of  the  uterus  is  probably  less  common  than  the  direct  infection  of 
the  veins  at  the  placental  site.  The  latter  is  the  first  and  commonest  seat  of 
puerperal  endometritis,  and  Lenhartz  states  that  at  least  one-half  of  all  puerpera 
who  come  to  the  autopsy-table  show  some  evidence  of  thrombophlebitis.  The 
streptococci  may  not  only  enter  the  lumen  of  the  veins,  but  may  also  proceed 
along  their  outer  walls  and  eventually  penetrate  them.  As  soon  as  the  thrombi 
once  become  infected,  it  is  no  longer  a  question  of  metritis,  for  the  disease  is 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     729 

propagated  along  one  or  more  of  the  uterine  veins,  and  we  have  special  con- 
secutive lesions. 

Consecutive  lesions  beyond  the  limits  of  the  uterus  must  now  be  considered. 
As  already  stated,  these  are  divisible  into  (i )  lesions  due  to  lymphatic  extension — 
parametritis,  ovaritis,  perimetritis  (or  benign  peritonitis),  and  general  or  malig- 
nant peritonitis — and  (2)  lesions  due  to  venous  extension,  which  comprise  the 
various  types  of  puerperal  phlebitis. 

X.  Parametritis. — This  lesion  is  caused  by  propagation  of  the  streptococci 
from  the  lymph  spaces  of  the  muscularis  of  an  infected  uterus  and  also  from 
extensive  cervical  puerperal  ulcers  which  extend  directly  into  the  parametrium. 
In  the  former  case  the  germs  are  propagated  along  the  pelvic  lymphatics  where 
they  set  up  a  lymphangitis;  while  in  the  latter  case  cellulitis  is  the  immediate 
result.     In  the  absence  of  natural  barriers  the  loose  tissue  of  the  pelvis  is  quickly 


/'%,. 


■■^"W.  :<*^~*sS^,^ 


,--  .sJi^ 


Fig.  951. — Uterus  and  Adnexa  from  a  Case  of  Acute  Streptococcus  Infection  and 
Septicemia  Lymphatica.  Death  on  twelfth  day  after  Cassarean  section.  No  peri- 
tonitis and  no  pus  in  the  tubes;  macroscopic  appearance  of  endometrium  normal. — 
(Author's  case  at  the  New  York  Maternity.*) 


infected.  The  parametrium  of  one  or  both  sides  becomes  the  seat  of  hyperemia 
and  serous  infiltration.  The  diseased  foci,  usually  miliary,  are  then  invested  by 
a  wall  of  leucocytes  which  limits  the  further  extension  of  the  process.  Abscess- 
formation  occurs  whenever  the  miliary  foci  coalesce,  but  the  natural  leucocyte 
defense  is  generally  so  vigorous  that  the  streptococci  are  vanquished  at  an  early 
stage  before  coalescence  occurs.  In  this  termination  the  exudation  is  gradually 
absorbed.  When  abscess-formation  occurs  the  pus  tends  to  gravitate  into  the 
perirectal  and  retroperitoneal  connective  tissue.  The  abscess  may  penetrate 
into  the  rectum  or  vagina  or  may  point  externally  at  the  groin  above  Poupart's 
ligament.     (Figs.  954  and  955.) 

Parametritis  may,  of  course,  be  but  a  single  feature  in  a  compHcated  septic 
process,  in  association  with  endometritis  and  other  local  lesions  and  septicemia; 

♦See  "Trans.   N.  Y.   Obstetrical  Society,"  April   16,   1895. 


730 


PATHOLOGICAL  PUERPERIUM. 


but  when  parametritis  is  the  principal  lesion,  it  simply  gives  rise  to  the  same 
constitutional  reaction  as  does  any  other  large  acute  abscess,  and  it  would 
hardly  be  proper  to  rank  such  a  condition  as  puerperal  sepsis.  Thus,  invasion 
of  the  parametrium  is  heralded  by  a  chill  and  a  sharp  rise  of  temperature,  and 
a  typical  suppuration-fever  follows.  If  the  leucocyte  defense  succeeds  in  keeping 
the  minute  initial  abscesses  from  coalescing,  the  process  is  aborted  in  about 
ten  days  or  two  weeks  and  defervescence  results ;  but  if  the  streptococcus  pre- 
vails, the  gradual  formation  of  the  abscess  is  marked  by  the  usual  temperature 
curve  of  an  abscess  fever.  High  evening  temperatures  are  succeeded  by  profuse 
sweats  and  morning  remissions.  Relief  by  natural  or  surgical  evacuation  is 
followed  by  defervescence.  Clinically  the  rigor  and  rise  of  temperature  are 
associated  with  pain  and  tenderness  in  situ  and  in  some  cases  pressure-pain  is 
also  referred  to  the  lower  extremities  or  loins.  Bimanual  examination  reveals 
the  presence  of  a  mass  at  one  side  of  the  uterus  (exceptionally  at  both  sides); 
several  days,  however,  being  required  for  the  development  of  the  exudate.  The 
mass  at  the  side  of  the  uterus  tends  to  increase  in  size,  and  the  sensitiveness 


VAGINA 
RECTUM 

Fig.  952. — Parametric  Inflammation 
IN  THE  Cellular  Tissue  of  the 
Right  Broad  Ligament  Pushing 
THE  Uterus  to  the  Lbft .^(Dakin.) 


VAGINA 


Fig.  953. — Parametric  Inflammation  of 
THE  Cellular  Tissue  of  the  Right 
Iliac  Fossa,  and  Slight  Induration  in 
the  Right  Broad  Ligament.  The  Uterus 
is  in  the  Normal  Position. — (Dakin.) 


to  manipulation  increases,  especially  in  cases  in  which  the  peritoneum  becomes 
involved  secondarily.  The  respective  terminations  in  resolution  and  suppura- 
tion have  already  been  noted.  In  either  case  more  or  less  of  the  infiltration 
may  persist  as  organized  connective  tissue,  and  incidentally  the  uterus  may 
become  displaced  in  any  one  of  several  fashions. 

The  diagnosis  of  parametritis  is  naturally  considered  with  that  of  perimetritis, 
for  the  two  conditions  not  only  present  much  in  common,  but  very  often  coexist. 

XI.  Peritonitis. — Benign  Forms  Of. — Under  this  head  belong  various  types 
of  circumscribed  peritonitis  which  comprise  perimetritis,  perisalpingitis,  peri- 
oophoritis, etc.,  and  which  are  due  to  a  simple  extension  of  inflammation  from 
the  uterus,  parametrium,  tubes,  ovaries,  etc.  The  peritoneum  may  also  be 
involved  as  a  result  of  rupture  of  the  uterus,  of  a  parametritic  abscess,  and  of 
emigration  of  bacteria  (practically  only  the  gonococcus)  from  the  tube  into  the 
peritoneal  cavity.  Unless  the  bacteria  which  come  in  contact  with  the  peri- 
toneum possess  a  high  degree  of  virulence,  the  inflammation  remains  circum- 
scribed, chiefly  because  the  exudation  brings  about  adhesion  of  the  parietal  and 
visceral  peritoneum  with  resulting  encapsulation  of  germs.     The  systemic  reac- 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     731 

tion  in  these  cases  is  that  of  localized  peritonitis  rather  than  what  is  comprised 
under  puerperal  infection.  In  regard  to  the  genesis  of  peritonitis  in  the  puer- 
perium,  the  lymphatics  are  in  most  cases  the  organs  at  fault;  the  bacteria 
passing  from  the  lymph  spaces  of  the  uterus  directly  into  the  peritoneal  cavity 
Thus  perimetritis  becomes  much  the  more  common  localization.  The  other 
local  types  already  mentioned  occur  with  greater  infrequency,  by  reason  of  their 
special  etiology.  It  may  be  stated  that  a  severe  parametritis  almost  necessarily 
extends  to  the  peritoneum,  and  that  the  same  is  true  of  acute  salpingitis,  acute 
oophoritis,  etc.  When  peritonitis  results  from  rupture  of  the  uterus,  or  from  an 
acute  abscess,  etc.,  its  character  must  depend  wholly  upon  the  relative  virulence 
or  sterility  of  the  escaping  substances,  and  the  same  is  true  of  the  escape  of 


Deaenerated  fliop&oas  Muscle 
Abscess  Cavity 
CrunaL  Artery 

Crural  Vc/n 


li  icpsoas  Muscle 
Crura/  Vein 


DegencrcUe^  _ 
Int  ObUqiie       \> 
Muscle  \ 


Rl  Ureter 
Ant  LLpofCervi.jc 


Le/t  round 
Ligament 


SubperLtcn£cd 
Pus 


Le/t  Ureter 


Para,  vaainal 
Iri/la  rrCm/i  tion 


PeLvCc  Floor 


Pelvic  Floor 


Left  Va^y^aU 


Fig.  954. — Transverse  Section  of  the  Pelvis  from  a  Primipara  Four  and  a  Hal? 
Months  Post  Partum,  showing  Parametritis  and  the  Formation  of  Puerperal 
Pelvic  Abscesses. — (Sellheim.) 


pus  from  the  tubes  into  the  peritoneal  cavity.  In  all  such  cases  the  perimetrium 
is  necessarily  attacked.  Hence  for  practical  purposes  benign  peritonitis  is  vir- 
tually equivalent  to  perimetritis.     (Fig.  956.) 

Perimetritis. — This  condition,  like  endometritis  and  parametritis,  possesses 
a  distinct  clinical  individuality,  and  occurring  as  the  chief  clinical  feature  of  a 
morbid  puerperium  may  run  its  course  as  a  local  infection  with  its  natural 
systemic  reaction.  The  most  important  thing  to  know  about  perimetritis  is 
that  it  occurs  chiefly  from  propagation  of  bacteria  through  the  lymph  spaces 
of  the  muscularis  of  the  uterus,  without  the  necessary  production  of  a  high 
degree  of  metritis.  When  the  streptococci  enter  these  lymph  spaces,  it  is  only 
when  of  the  highest  virulence  that  they  occupy  the  finer  radicles  and  from  these 


732 


PA  THOLOGICAL  P  UERPERI UM. 


attack  the  muscular  substance.  Under  ordinary  circumstances  they  simply 
travel  along  the  coarse  spaces  until  the  peritoneum  is  reached;  so  that  peri- 
metritis is  much  more  likely  to  result  than  severe  metritis.  Through  this  pecu- 
liarity we  are  able  to  imderstand  why  bacteria  of  low  virulence,  such  as  the 
gonococcus  and  even  saprophytes  (as  Ahlfeld  implies) ,  may  in  some  cases  reach 
the  peritoneum  and  set  up  a  low  grade  of  perimetritis.  Ahlfeld  believes  that 
the  puerperium  often  rouses  to  activity  a  preexistent  slight  localized  perimetritis, 
especially  in  latent  gonorrhea. 

The  course  of  benign  peritonitis  has  already  been  stated.  The  exudate  which 
is  shut  off  by  adhesions  may  be  either  serofibrinous  or  purulent.  Of  great 
interest  is  the  frequent  occurrence  in  pus  of  this  source  of  the  bacillus  coli, 
which  is  believed  to  pass  through  the  intestinal  wall  after  adhesions  have  formed . 


Sacro- iliac  ArticulatioTt 
Intrapert^ncaZpus 
fi/ri/drm  mtisc/a 
JsdiialTieric 


Ifi/pogcatric 
Greater  tschial/oramer 
Jitjpo^astnc  Vet?i 
Ureter 


UterimArt 

Jnte7mxl  Obturator  mtiscle 
TArombus  Obturator  Vem 

Obturator  Fora?nen  ~ 
Internal ObmmtOr.mus  ~ 
Pectinsus  muscle 

/idductormttsde 


Rtrareetai  eztmpentonealpu.^  camti/ 
Ischial  nerve 
Superior  ^lutealArt. 
IJtfpc^astncArt. 

Ureter 

nrmnbus  g^ffifjogastric  VHtv 
Intrafjento^eal  pits  cavitij' 


Uteri7ie/n 
TJirombus 

Of  Otftwator  Veitv 
-  Umnne&odt/ 

^■Viti/(^Ut(^rU3  wizh  blood-clot 
Fu^  in  utero  >jes.pouc}i 


Bl'Mlder 


M  0  N5 


Fig.  955. — Horizontal  Section  of  a  Pelvis  from  a  Primipara  Three  Weeks  Post 
Partum,  showing  Abscess  Cavities  in  Utero-vesical  Pouch,  in  Douglas's  Cul- 
de-sac,  AND  also  Pararectal  and  Extraperitoneal  Suppuration. — {Sellheim.) 


When  pus  forms  in  connection  with  perimetritis,  the  almost  invariable  result  is 
intestinal  perforation. 

While  perimetritis  may  occur  as  part  of  a  general  septic  process,  or  in  asso- 
ciation with  parametritis,  it  may  also  in  certain  cases  constitute  the  principal 
feature  of  the  puerperal  morbidity,  especially  in  the  cases  described  by  Ahlfeld 
in  which  an  old  perimetritis  is  roused  to  activity  by  labor.  Under  such  circum- 
stances we  should  expect  to  see  the  symptoms  of  an  ordinary  peritoneal  reaction, 
including  great  pain  and  tenderness,  small,  rapid,  and  incompressible  pulse,  rapid 
breathing,  thirst,  and  vomiting.  The  patient  lies  in  the  dorsal  position  with 
knees  drawn  up  to  diminish  abdominal  tension.  Perimetritis  is  ushered  in  by 
a  chill  and  a  sharp  rise  of  temperature,  which  continues  moderately  high 
and  without  morning  remissions  while  somewhat  higher  at  night.  When  pus 
forms,  a  second  chill  and  renewed  ascent  of  temperature  occur.  After  perime- 
tritis has  lasted  for  several  days  the  presence  of  the  exudate  may  be  made  out  in 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     733 

Douglas'  cul-de-sac,  or  in  some  cases  in  the  entire  lesser  pelvis.  This  having 
become  encapsulated,  the  uterus  is  immobilized.  If  suppuration  does  not  occur, 
this  exudate  may  be  absorbed  after  several  weeks;  but  with  the  formation  of 
pus,  softening  and  fluctuation  become  apparent,  and  the  abscess,  as  already 
stated,  may  be  expected  to  rupture  into  the  intestine,  or  exceptionally  into  the 
vagina,  or  externally,  or  even  through  the  limiting  wall  into  the  general  peri- 
toneal cavity.  The  diagnosis  of  perimetritis  should  not  be  difficult,  since  the 
phenomena  of  the  peritoneal  reaction  are  so  characteristic.  The  chief  point  of 
interest  lies  in  distinguishing  at  the  outset  between  perimetritis  and  parametritis ; 
since  both  affections  begin  at  about  the  third  or  fourth  puerperal  day  with  a  chill 
and  sharp  rise  of  temperature,  and  are  attended  with  pain,  tenderness,  and  the 
formation  of  plastic  material.  The  peritoneal  reaction  should  be  sufficient  for 
discrimination.  It  frequently  happens  that  the  two  affections  coexist,  and  in 
this  case  the  symptoms  of  parametritis  are  naturally  masked,  and  a  bimanual 
examination  becomes  indicated,  which,  owing  to  the  great  pain  and  tenderness 
resulting,  can  with  difficulty  be  carried  out. 

General  or  Malignant  Peritonitis. — Bacteria  of  comparatively  low  virulence 
bring  about  benign  peritonitis  or  perimetritis;  and  under  precisely  the  same 
circumstances,  highly  virulent  germs  cause  a  general  peritonitis.  According  to 
the  general  teaching  the  latter  affection  follows  most  commonly  upon  an  en- 
dometritis set  up  by  highly  infectious  germs ;  Lenhartz,  however,  has  shown 
the  great  relative  frequency  with  which  severe  parametritis  can  bring  about 
malignant  peritonitis.  But  this  affection  is  not  due  necessarily  to  lymphatic 
extension,  since  it  may  result  from  direct  inoculation  of  the  peritoneum  by  the 
contents  of  a  ruptured  uterus  or  a  preexisting  abscess.  It  has  been  commonly 
taught  that  malignant  peritonitis  is  usually  a  complication  or  feature  of  severe 
general  sepsis,  both  being  the  natural  consequence  of  highly  virulent  strepto- 
cocci ;  but  many  case-histories  seem  to  show  that  the  general  condition  in  malig- 
nant peritonitis  is  not  septic  infection  of  the  blood,  but  profound  toxemia  caused 
by  the  rapid  multiplication  of  germs  over  the  entire  peritoneal  surface.  In 
other  words,  malignant  peritonitis  may  often  represent  a  purely  local  infection, 
limited  only  by  the  great  extent  of  the  peritoneum. 

Malignant  peritonitis  is  undoubtedly  due  to  the  high  virulence  of  bacteria 
which  spread  over  the  peritoneal  surface  without  any  attempt  at  the  formation 
of  isolating  adhesions.  It  does  not  appear  that  the  germs  are  necessarily  of 
unusual  virulence  before  gaining  the  peritoneum,  but  may  find  conditions  there 
which  favor  their  rapid  multiplication. 

Case-histories  show  that  a  woman  may  be  fatally  septic  and  yet  have  only  a 
localized  peritonitis ;  while  as  already  stated,  complete  purulent  peritonitis  may 
not  be  accompanied  by  general  sepsis.  (Fig.  956.)  There  is  much  evidence  to 
show  that  lymphogenic  malignant  peritonitis  is  a  phase  of  puerperal  morbidity 
which  is  sui  generis,  bearing  no  definite  relationship  to  perimetritis,  endometritis, 
or  septic  infection  of  the  blood.  It  is  preeminently  a  streptococcus  disease. 
The  symptoms  are  those  of  general  peritonitis  from  other  causes.  The  most 
striking  symptom  is  the  extreme  degree  of  meteorism  which  results  from  intes- 
tinal paresis,  and  which  produces  compression  of  the  thorax  and  dyspnea.  The 
prodigious  amount  of  toxins  produced  and  absorbed  tends  to  overwhelm  the 
heart,  and  the  pulse-rate  rapidly  mounts  to  the  neighborhood  of  150.  Ahlfeld 
regards  malignant  peritonitis  as  essentially  a  disease  of  the  very  early  puer- 
perium — ^jnost  frequently  of  the  first  day.  The  chill  is  often  wanting,  and 
the  rapid  supervention  of  great  agony  referred  to  the  bowels;  vomiting, 
restlessness,  and  anxiety  suggest  that  the  patient  has  swallowed  an  irritant 


734 


PATHOLOGICAL  PUERPERIUM, 


Peritoneum  covered 
with  fibrin  atid 
pus. 


Unaffected  muscle 


I  Portion  of    muscle 
omitted. 


Moderate      exuda- 
tive endometritis . 


Fig.  956. — Section  through  the  Wall  of  a  Uterus  showing  Streptococcus  Endo- 
metritis, AND  Extension  of  the  Infection  through  the  Lymphatics  to  the  Peri- 
toneum, Causing  Peritonitis.  Death  on  the  thirteenth  day  post  partum,  after  a 
full-tenn  dehvery,  from  general  purulent  peritonitis  and  exhaustion.  Patient  was 
at  first  treated  on  the  basis  of  a  diagnosis  of  acute  malarial  infection.  No  local  treat- 
ment was  at  any  time  used.  X  75. — {From,  a  specimen  in  the  Pathological  Laboratory 
of  Cornell  University  Medical  College.) 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.     735 

poison.  Lenhartz,  however,  described  an  entirely  different  course,  in  which 
the  puerperium  begins  favorably,  then  parametritis  develops,  and  eventually 
general  peritonitis ;  the  evolution  of  the  disease  being  much  less  fulminant.  He 
found  the  symptoms  to  occur  in  the  following  order:  chill  (always  present); 
vomiting;  abdominal  pain;  diarrhea.  These  were  succeeded  by  great  weakness 
and  meteorism.  All  authors  speak  of  the  euphoria  and  mental  clearness  which 
are  sometimes  presented  by  women  who  are  already  nearly  pulseless.  They  no 
longer  feel  pain  nor  distress.  As  the  symptomatology  of  this  condition  agrees 
with  that  of  acute  general  peritonitis  from  other  causes,  further  details  may  be 
omitted. 

The  diagnosis  should  be  self-evident  and  the  prognosis   is  all  but  hopeless. 
Since  occasional  recoveries  occur,  the  selection  of   favorable  cases  becomes  of 
great  importance.     As  the  bacteria  spread  over  the  peritoneum  and  proliferate, 
with  production  of  tox- 
ins, a  serofibrinous  exu-  ^, 
date      appears      which                             .■f°~W'  n,         ^ 
tends  to  become  puru-  "'*     ^ 
lent. 


Consecutive  Lesions  from       M     -  -      _     ■»« 

Venous  Extension.  -^  -         , 

XII.     Metrophlebitis,  "  -' V 

Septic  Phlebitis,  or  Sep-  """'  ^^    ^-'L,-^  '' 

ticaemia   Venosa.  —  The  .  ' 

microorganisms      which  ** 

cause  infection  may  gain  ^  .  "^ 

access  to  the  circulation  ~*'^^  ^  .C 

in    two   ways:     by   the  "^^  '  7,      J  ' 

lymphatics    (Fig.    956),  ^      *  -^  '^  '■ 

as  already  noticed,  and  ^,  - 

by  the  veins  (Figs.  937,  % 

938).    The  placental  site 

is  naturally  most  likely 

to  be  the  starting-point  pj^^  g^j — Small  Blood-vessel  from  the  Endometrium 
of    the    latter    process.  of  Fig.  956,  showing  Streptococci  among  the  Blood 

The    diffusion    through  ^^°  Endothelial  Cells.     X  700. 

the   general   circulation 

of  pyogenic  organisms  and  the  transportation  of  these  organisms  to  distant  tissues 
and  organs  give  rise  to  a  long  train  of  symptoms  and  complications  which 
are  usually  grouped  under  the  name  pyemia.  Some  of  these  complications, 
however,  may  occur  as  the  result  of  other  varieties  of  sepsis;  e.  g.,  endocarditis 
is  sometimes  seen  in  connection  with  the  lymphatic  form  of  sepsis  and  arthritis 
may  occur  when  the  infection  is  due  to  gonorrhea. 

Uterine  and  Para-uterine  Phlebitis. — Pathology:  Thrombosis  of  the 
uterine  or  pelvic  veins  is  not  a  rare  occurrence  (Fig.  978).  Uterine  re- 
relaxation  predisposes  to  its  development.  Normally  a  thrombus  becomes 
organized  and  converted  into  an  impervious  cord  of  tissue,  or  a  channel  may 
be  formed  and  the  circulation  re-established.  When  a  thrombus  becomes 
infected,  which  naturally  happens  most  frequently  at  the  placental  site,  it 
disintegrates,  and  fragments  may  be  carried  to  distant  parts  of  the  body. 
Septic  phlebitis  may  occur  when  the  vessel  is  surrounded  by   infected    tissue. 


736  PATHOLOGICAL  PUERPERIUM. 

In  this  case  the  endothelium  proliferates  and  thrombi  occur.  Thrombi 
resulting  from  phlebitis  may  remain  organized,  but  usually  become  puru- 
lent; and  we  then  have  abscesses  in  the  uterine  wall  and  the  extension 
of  the  process  along  the  veins  of  the  pelvis.  When  in  a  case  of  endome- 
tritis the  necrosed  endometrium  at  the  placental  site  is  removed,  the 
thrombi  are  found  to  be  but  little  affected.  Extension  of  endometrial  infection 
along  the  placental  thrombi  does  not  ordinarily  occur.  Organization  of  the 
thrombi  is  to  be  regarded  as  Nature's  safeguard  against  infection,  and  probably 
organization  in  the  deeper  layers  has  already  occurred  before  labor.  When, 
however,  the  organisms  possess  a  high  degree  of  virulence,  or  when  they  gain 
access  to  the  placental  sinuses  before  or  early  in  the  course  of  labor,  the  thrombi 
remain  soft  and  permit  the  propagation  of  the  bacteria,  and  cases  of  severe 
infection  may  be  marked  by  the  breaking-up  of  thrombi  already  organized. 

Etiology:  The  usual  causes  of  sepsis  are,  of  course,  operative.  Manipulations 
about  the  placental  site  seem  to  constitute  a  predisposing  cause.  This  type 
of  infection  has  often  been  noticed  in  sepsis  from  retained  placenta,  in  cases 
of  placenta  praevia,  and  after  manual  separation  of  the  placenta.  Infection 
occurring  early  in  labor,  before  the  organization  of  the  placental  thrombi,  is 
especially  apt  to  result  in  uterine  phlebitis.  Symptoms:  These  generally  appear 
rather  late  in  the  puerperium,  perhaps  at  the  end  of  a  week  or  two,  although 
they  have  been  noted  three  or  four  days  after  delivery  and  as  late  as  three 
weeks  and  more.  There  is  a  sudden  rise  of  temperature  to  103°  or  105°  F.,  and 
the  pulse  becomes  rapid.  A  chill  is  not  usually  present.  The  fever  soon 
becomes  remittent  or  intermittent,  profuse  sweats  occur  at  intervals,  and 
there  are  evidences  of  great  prostration.  Diagnosis:  Bimanual  examination 
shows  no  subinvolution  or  special  sensitiveness  or  exudation  as  in  pelvic  peri- 
tonitis or  cellulitis.  In  some  cases  sudden  and  severe  hemorrhage  may  occur 
from  the  disintegration  and  dislodgment  of  infected  thrombi.  The  diagnosis 
is  based  upon  the  symptoms  mentioned  above,  together  with  the  negative 
results  upon  external  and  bimanual  examination.  Prognosis:  This  is  grave, 
not  only  on  account  of  the  danger  inherent  in  the  condition,  but  of  the  various 
complications  which  may  ensue  in  the  course  of  a  metastatic  pyemia. 

Femoral  Phlebitis,  or  Phlegmasia  Alba  Dolens. — This  condition 
is  still  called  "milk-leg"  by  the  laity,  and  was  formerly  supposed  to  be 
due  to  metastasis  of  milk.  It  is  characterized  by  venous  obstruction  and 
enormous  swelling  of  the  leg.  Pathology:  It  occurs  in  two  forms — the  thrombo- 
phlehitic  and  the  cellulitic.  The  first  is  much  more  common.  The  two  varieties 
may  be  combined,  since  a  phlebitis  may  lead  to  inflammation  of  surround- 
ing structures,  and,  vice  versa,  a  cellulitis  may  cause  phlebitis  or  thrombosis. 
The  student  will  notice  that  phlegmasia  may  occur  as  a  complication  either 
of  uterine  phlebitis  or  of  cellulitis — much  more  commonly,  however,  of  the 
former.  The  thrombo-phlebitic  form  may  arise  in  two  ways:  either  by  the 
extension  of  a  septic  inflammation  of  the  walls  of  the  vessel  from  the  placental 
site,  with  resulting  clotting  of  blood  in  the  vessel,  or  by  primary  thrombosis. 
According  to  Widal,  micro-organisms  are  especially  prone  to  attack  the  wall 
of  the  femoral  vein  near  Poupart's  ligament,  the  circulation  being  notably 
sluggish  at  this  point,  and  particularly  so  when  the  patient  first  assumes  the 
erect  position  after  delivery.  Etiology:  The  condition  is  usually  to  be  regarded 
as  a  result  of  septic  infection.  The  method  of  extension  is  made  clear  by  the 
pathology.  It  is  possible  that  it  is  occasionally  non-septic  in  origin.  Among 
the  causes  which  may  predispose  to  non -septic  thrombosis  may  be  mentioned 
slowing  of  the  circulation,  as  in  varicose  veins.     Symptoms:  In  the  thrombo- 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.    737 

phlehitic  form  the  symptoms  usually  appear  two  or  three  weeks  after  delivery, 
and  often  after  the  patient  has  been  up  for  a  few  days.  As  in  other  forms 
of  infectious  phlebitis,  there  are  fever  and  perhaps  chilly  sensations  and  a  chill. 
The  tongue  is  coated  and  there  are  evidences  of  gastro-intestinal  disturbance, 
loss  of  appetite,  constipation,  eructations,  nausea,  and  vomiting.  There  is  a 
feehng  of  weight  and  stiffness  in  the  leg.  Pain  in  the  calf  of  the  leg  is  often 
a  prominent  symptom.  There  may  be  tenderness  along  the  course  of  the 
femoral  vein  which  may  be  marked  by  a  red  line.  Sometimes  other  superfi- 
cial veins  present  similar  signs.  The  leg  swells  rapidly  from  below  upward 
and  soon  attains  an  enormous  size.  When  the  swelling  is  at  its  height,  the 
skin  is  so  tense  as  not  to  pit  on  pressure.  In  the  celluUtic  form  the  symptoms 
are  in  many  respects  similar,  but  the  swelling  is  from  above  downward  and 
there  are  the  accompanying  evidences  and  previous  history  of  pelvic  cellulitis. 
The  left  leg  is  affected  oftener  than  the  right.  In  some  instances  though  be- 
ginning in  one  leg,  the  other  after  a  brief  interval  is  also  affected. 

The  foregoing  lesions  have  been  considered  because  they  frequently  occur 
in  cases  of  metastatic  pyemia,  but  it  is  easy  to  see  that  the  list  might  be  in- 
definitely multiplied.  Wherever  an  infected  embolus  finds  lodgment,  metastatic 
abscesses  may  occur.  The  liver,  kidneys,  and  spleen,  and  even  the  brain  and 
eye,  have  been  so  affected.  Parotitis  has  been  observed;  multiple  abscesses  in 
the  muscles  and  connective  tissue  and  diffuse  cellulitis  may  occur.  Pleuritis 
and  pericarditis  are  common. 

XIII.  Specific  Diseases. — Originating  Intragenitally. — Here  belong  three 
diseases  which  are  capable  of  producing  diffuse  primary  inflammation  of  the 
genital  passages,  followed  by  toxemia  or  bacteriemia.  The  disease  is  contracted 
in  most  cases  from  an  individual  having  the  same  affection ;  and  herein  it  differs 
from  ordinary  infection,  which  does  not  represent  the  extension  of  a  specific 
infectious  disease.  (i)  Gonorrhea:  According  to  Ahlfeld,  the  gonococcus  is 
found  with  surprising  frequency  in  the  vaginal  secretions  of  a  pregnant 
woman.  It  is,  however,  usually  present  in  small  numbers.  (Fig.  947.)  But 
after  delivery  we  may  find  in  the  same  subject  that  the  number  has  greatly 
augmented.  This  rule  is  believed  to  hold  good  for  the  endometrium,  tubes,  and 
peritoneum;  so  that  when  a  puerpera  develops  clinical  gonorrhea,  we  are  not 
to  think  first  of  an  infection  from  without.  The  latter,  however,  is  possible; 
obstetricians  do  not  usually  describe  a  puerperal  gonorrheal  vulvitis  or  vaginitis, 
although  such  might  readily  occur  under  conditions  of  exposure.  Infection  of 
the  newly  born  usually  arises  from  endocervicitis.  A  puerpera  with  pre-existing 
gonorrheal  endometritis,  salpingitis,  etc.,  may  develop  fever  from  gonococcus 
toxins  or  very  rarely  actual  gonococcus  sepsis  with  metastases.  (2)  Diphtheria  : 
True  diphtheria  may  occur  in  the  vulva  and  vagina,  either  in  patches  upon 
wounds  made  in  delivery,  or  as  a  continuous  membrane.  It  may  represent  a 
primary  inoculation  or  be  secondary  to  faucial  diphtheria.  High  temperature 
and  other  accidents  due  to  toxemia  occur,  but  sepsis  is  excluded  by  the  nature 
of  the  disease,  which  readil}'' yields  to  antitoxin.  (3)  Erysipelas:  It  has  usually 
been  believed  that  a  puerperal  woman  exposed  to  erysipelas  contracts  ordinary 
puerperal  fever,  owing  to  the  apparent  identity  of  the  streptococcus  erysipelatis 
and  streptococcus  pyogenes.  However,  these  women  sometimes  contract  true 
erysipelas  which  begins  in  the  cutaneous  aspect  of  the  vulva.  Some  authors 
mention  a  diffuse  inflammation  of  the  genital  tract.  Ahlfeld  mentions  an  ery- 
sipelatous inoculation  of  birth-traumatisms.  Good  descriptions  of  all  these 
focal  affections  are  difflcult  to  find  in  literature.  We  may  expect  to  see  bac- 
teriemia develop  in  these  cases.  Whenever  a  puerpera  is  attacked  by  ordinary 
47 


738  PATHOLOGICAL  PUERPERIUM. 

facial  erysipelas,  we  do  not  usually  see  an  implication  of  the  genitals.  (4)  Mis- 
cellaneous: Theoretically  any  infectious  bacterium  might  set  up  local  intragenital 
lesions  in  the  puerpera.  The  bacillus  of  tetanus  produces  no  known  local  altera- 
tion in  the  puerperium;  hence  this  condition  may  be  discussed  under  toxemia. 
When  germs  like  the  bacillus  coli  and  pneumococcus  cause  focal  affections  they 
are  indistinguishable  save  by  the  microscope  and  by  cultures  from  ordinary  pyo- 
genic infection. 

Originating  Extragenitally. — Of  the  acute  infectious  diseases,  a  certain 
number  tend  to  cause  focal  affections  of  the  genitals ;  so  that  if  a  puerpera  should 
contract  one  of  these  diseases  we  naturally  expect  to  see  the  formation  of  hematog- 
enous genital  lesions.  Thus  cholera  and  other  severe  diseases  produce  endometritis, 
which,  occurring  in  the  recent  puerperal  uterus,  might  readily  cause  hemorrhage. 
(Vinay  mentions  only  a  single  case  of  post-partum  hemorrhage  in  connection  with 
puerperal  cholera.)     Variola  should  give  rise  to  a  specific  vaginitis  as  well. 

Metastatic  Focal  Infection. 
Metastatic  Lesions. — These  develop  only  after  the  establishment  of  bacteri- 
emia,  with  which  they  are  necessarily  associated.  Speaking  generally,  when  a 
woman  has  once  become  septic  her  condition  should  not  differ  materially  from 
that  of  septic  patients  in  general;  and  the  subject  of  metastases  might  well  be 
left  to  general  treatises  on  pathology.  Most  authors  describe  some  of  the  more 
commonly  occurring  and  important  metastases  in  this  connection,  such  as  endo- 
carditis, pneumonia,  various  dermatoses,  etc.  According  to  Lenhartz,  pulmo- 
nary abscesses,  as  a  rule,  represent  the  only  form  of  suppurative  metastasis;  next 
in  frequency  come  intramuscular  and  intra-articular  or  periarticular  lesions, 
affecting  by  preference  the  knee.  Very  rare  metastases  are  those  of  the  eye 
(panophthalmitis)  and  meninges.  Other  metastases  are  renal  and  splenic  in- 
farcts, cutaneous  hemorrhages,  and  pustular  eruptions.  An  important  lesion  of 
sepsis  not  always  classed  among  ordinary  metastases  is  endocarditis,  which  is  in 
itself  responsible  for  metastases  of  the  eye,  meninges,  etc. 

BLOOD-STATES  OR  GENERAL  CONDITIONS. 
Simple  Blood-state  or  General  Condition. 

I.  Sapremia. — Sapremia  is  a  blood  or  general  state  characterized  by  the  ab- 
sorption of  decomposition-products  of  putrefying  tissue.  While  often  spoken  of 
indifferently  as  toxemia,  it  is  of  a  different  character  from  the  toxemia  of  bacterial 
origin.  While  the  saprophytes,  which  set  in  motion  the  putrefactive  changes  in 
the  dead  tissue,  secrete  poisonous  substances,  these  must  be  greatly  overshadowed 
in  importance  by  the  decomposition  products  of  the  tissues  themselves.  Sapre- 
mia is  therefore  a  sort  of  ptomainemia.  The  substances  which  by  their  decom- 
position furnish  these  toxic  substances  are  varied,  comprising  retained  placenta 
and  decidua,  pent-up  lochia,  the  retained  ovum  or  fetus  in  missed  labor,  por- 
tions of  gangrenous  uterus,  fibroid  tumors,  etc.,  etc.  The  necrotic  surface  of 
puerperal  ulcers  is  also  a  source  of  sapremic  intoxication,  and  according  to  some 
authorities,  this  is  even  true  of  the  tissue  cast  off  during  normal  regeneration  of 
the  endometrium. 

Lenhartz  believes  that  pure  sapremia  is  not  so  frequent  as  has  been  believed, 
and  that  a  bacteriemia  often  coexists.  Clinically  the  phenomena  of  sapremia 
depend  upon  the  amount  of  poisonous  matter  absorbed.  In  the  most  fulminant 
cases  we  see  the  picture  of  a  most  intense  toxemia.  There  is  a  chill,  followed 
by   high   fever,   headache,    vomiting,   and   complication  of  the  higher  nervous 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.    739 

centers,  as  shown  by  motor  excitement  and  delirium.  Meteorism  is  present, 
as  a  rule,  so  that  the  dyspnea  of  fever  is  increased.  The  pulse  may  reach  i6o. 
In  the  most  fulminant  forms  the  patient  may  die  in  the  first  twenty-four  or 
forty-eight  hours  or  she  may  linger  for  one  or  two  weeks.  There  is,  as  a  rule, 
no  tendency  to  compromise  permanently  important  organs,  so  that  in  pure 
sapremia  striking  improvement  follows  the  removal  of  the  putrefying  material. 
In  fatal  cases  the  same  alterations  are  found  as  in  non-metastatic  septicemia. 

Every  degree  of  sapremia  may  be  encountered  between  the  acute  fulminant 
type  and  the  "one-day  "or  even  "one-hour"  rise  of  temperature  seen  in  a  large 
proportion  of  normal  puerpera. 

Of  considerable  interest  in  this  connection  is  the  possibility  of  a  different 
type  of  sapremia  due  to  intestinal  resorption  incidental  to  the  prolonged  consti- 
pation of  the  puerperal  week  when  the  bowels  are  not  artificially  relieved.  In 
cases  in  which  the  woman's  bowels  have  not  been  relieved  before  delivery,  this 
species  of  sapremia  might  antedate  labor.  It  is  true  that  Kustner  and  Zange- 
meister  have  apparently  shown  independently  that  constipation  on  one  hand, 
and  the  routine  use  of  castor  oil  on  the  other,  have  no  effect  on  the  temperature 
of  the  puerpera,  which  when  elevated  must  be  due  to  sapremia  from  the  uterus. 
But  a  few  experiments  made  perhaps  upon  phlegmatic  peasants  will  hardly 
convince  American  practitioners  that  women  in  this  country  do  not  develop 
a  rise  of  temperature  in  many  cases  when  the  bowels  are  confined  and  dis- 
tended with  gas.  It  is  true  that  toxemia  of  intestinal  origin  (stercoremia)  may 
not  be  the  cause  of  rise  of  temperature,  for  the  latter  may  be  due  to  reflex  ex- 
citation of  the  heat  center  by  the  distended  bowels. 

II.  Bacterial  Toxemia. — Pure  Toxemia  of  Bacterial  Origin. — This  con- 
dition frequently  accompanies  the  puerperium,  where  it  may  be  caused  by  the 
ordinary  pyogenic  cocci,  and  exceptionally  by  the  tetanus  bacillus,  Klebs- 
Loetfier  bacillus,  etc. 

Pyogenic  Cocci. — Wherever  there  is  an  acute  local  suppurating  focus  in  the 
puerperal  genitals,  we  almost  invariably  see  the  development  of  the  toxemia, 
which  is  a  feature  of  the  ordinary  surgical  or  wound  fever.  While  this  may 
readily  be  complicated  by  sapremia,  whenever  necrosis  or  imperfect  drainage 
leads  to  putrefactive  changes,  a  pure  toxemia  is  of  common  occurrence,  especially 
in  abscess  formation,  or  wherever  saprophytes  may  be  excluded.  Walthard  and 
others  have  made  the  claim  that  the  streptococcus  itself,  when  of  low  virulence, 
may  act  as  a  saprophyte,  feeding  on  dead  tissue  only  and  setting  up  sapremia 
in  addition  to  the  secretion  of  its  proper  toxins.  He  thus  holds  the  streptococcus 
responsible  for  some  of  the  mild  resorption  fever  which  is  present  in  a  normal 
puerperium.  Such  a  condition  would  naturally  belong  to  sapremia.  It  is 
otherwise,  however,  in  some  of  the  severe  focal  affections  of  the  puerperium. 
Thus  in  a  pure  streptococcus  endometritis  with  an  efficient  leucocyte  bar- 
rier against  extension  by  the  lymphatics;  in  a  parametritic  abscess;  in  local 
suppurative  peritonitis,  and  even  in  some  cases  of  fatal  general  peritonitis,  the 
accompanying  blood-state  is  a  pure  toxemia  without  any  evidence  of  bacteri- 
emia,  whether  bacteriological  or  clinical.  It  is  therefore  a  mistake  to  speak  of 
such  affections  as  varieties  of  sepsis.  They  represent  only  toxemia,  although 
very  prone  to  lead  to  sepsis.  In  a  certain  class  of  cases  the  bacteria  reach  the 
blood,  yet  clinically  the  condition  is  still  a  toxemia.  In  the  majority  of  cases 
of  bacterial  toxemia,  recovery  is  the  rule,  whether  or  not  abscess-formation 
occurs.  An  exception  is  furnished  by  acute  general  peritonitis,  owing  to  the 
great  extent  of  surface  involved,  and  the  fatal  degree  of  the  toxemia,  which 
overwhelms  the  heart. 


740  PATHOLOGICAL  PUERPERIUM. 

Puerperal  gonorrhea  may  be  accompanied  by  toxemia,  rarely  by  bacteri- 
emia  as  well  (gonococcus-sepsis). 

The  suppurative  focus  may  be  extragenital.  This  is  illustrated  by  mastitis 
developing  near  term,  the  toxemia  extending  into  the  puerperium. 

Bacterial  Toxemia  of  Tetanus. — It  is  well  known  that  the  tetanus  bacillus 
sometimes  reaches  the  uterus,  not  only  from  direct  transportation  (usually  in 
connection  with  attempts  at  criminal  abortion),  but  in  purely  spontaneous  labors 
in  unexamined  women.  The  tetanus  germ  does  not  induce  any  local  lesion,  but 
its  toxins,  formed  in  situ,  are  absorbed  with  the  production  of  the  full  clinical 
picture  of  tetanus.  Sapremia  or  sepsis  or  both  may  of  course  coexist.  Vinay 
has  reported  io6  cases,  in  37  of  which  there  had  been  operative  interference. 
Hirst  has  reported  three  cases  in  which  the  disease  was  apparently  due  to  in- 
jections of  unboiled  river- water.  According  to  Heyse,  a  previous  septic  infection 
is  always  necessary  to  pave  the  way  for  the  tetanus  bacillus.  This  claim  has, 
however,  been  denied.  The  symptoms  and  etiology  are  practically  those  of 
tetanus  in  the  non-pregnant  state.  Premature  emptying  of  the  uterus  seems 
to  be  a  predisposing  cause,  since  the  disease  develops  oftener  under  these  cir- 
cumstances than  after  labor  at  full  term.  In  my  study  of  635  cases  of  prema- 
ture interruption  of  pregnancy,  no  tetanus  occurred.  The  diagnosis  can  present 
little  difficulty,  although  the  affection  has  been  confounded  with  hysteria.  The 
condition  is  usually  fatal. 

Bacterial  Toxemia  of  Diphtheria. — This  occurs  in  primary  diphtheria 
of  the  puerperal  genitals,  in  ordinary  diphtheritic  angina,  etc.,  as  a  con- 
current affection.  Unless  some  associate  infection  or  intoxication  is  present,  we 
have  the  pure  toxemia  which  characterizes  simple  diphtheria. 

Puerperal  Toxic  Erythema. — As  already  mentioned,  an  erythematous 
rash  is  not  infrequently  noticed  during  the  puerperium.  It  may  occur  in  cases 
of  profound  toxemia  or  in  mild  cases.  Its  principal  importance  is  that  it  has 
been  frequently  mistaken  for  scarlet  fever.  I  have  in  three  instances  been 
asked  to  see  cases  ol  so-called  puerperal  scarlatina  which  proved  to  be  septic 
erythema.  In  one  case  the  patient  was  about  to  be  transferred  to  the  Hospital 
for  Contagious  Diseases.  The  rash  is  attended  b}^  itching  and  sometimes  by 
desquamation.  It  is  usually  regarded  as  due  to  Nature's  effort  to  eliminate 
toxic  materials  by  the  skin.  (See  Fever  Due  to  Intercurrent  and  Complicating 
Diseases.) 

Puerperal  Pemphigus. — Very  rarely  the  occurrence  of  a  pemphigoid  erup- 
tion in  connection  with  mild  cases  of  sepsis  has  been  noted.  The  fact  that  it 
spreads  rapidly  through  a  lying-in  ward  indicates  a  specific  infection  of  some  kind. 
Isolation  and  the  treatment  of  the  coexisting  sepsis  are  of  course  indicated. 

Puerperal  Toxic  Neuritis. — This  has  been  described  by  Mobius,  Laury, 
and  others.  It  may  occur  in  the  course  of  a  general  toxemia,  and  most  commonly 
affects  the  arms,  taking  the  form  of  a  bilateral  median  and  ulnar  neuritis,  but 
the  involvement  of  many  other  nerves  has  been  noticed.  The  spinal  cord 
may  be  affected.  In  other  cases  it  may  be  the  result  of  direct  extension  of 
the  infectious  process,  as  in  cases  of  pelvic  exudation.  There  is  also  a  non- 
toxic variety,  due  to  pressure  upon  the  nerve  structures  by  the  fetal  head, 
the  gravid  uterus,  or  instruments.  It  is  most  likely  to  occur  in  cases  of  pelvic 
deformity.  (See  page  769.)  The  symptoms  and  diagnosis  are  the  same  as  in 
the  non-puerperal  condition  together  with  those  of  coexisting  toxemia. 

This  affection  must  hot  be  confounded  with  polyneuritis  due  to  the  toxemia 
of  pregnancy,  which  may  extend  into  or  develop  during  the  puerperium. 

III.  Pure  Bacteriemia. — This  condition  denotes  the  presence  of  bacteria  in 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.  741 

the  blood  without  the  association  of  bacterial  toxins.  Naturally  the  bacteria 
must  be  of  very  low  virulence.  Pure  bacteriemia  has  been  found  on  several 
occasions  by  Lenhartz  in  blood  examinations  made  in  connection  with  endo- 
carditis. Despite  the  constant  presence  of  streptococci  in  the  blood  for  weeks 
and  even  months,  no  further  symptoms  were  produced,  and  the  temperature 
was  practically  within  normal  limits.  Pure  bacteriemia  must  occur  occasionally 
in  the  puerperium,  as  shown  in  cases  of  uncomplicated  endocarditis,  following 
slight  genital  lesions.  In  the  vast  majority  of  cases,  bacteriemia  is  associated 
with  toxemia,  constituting  septicemia. 

Composite  or  Septic  Blood-states  or  General  Conditions. 

IV.  Bacteriemia  with  Toxemia. — i.  Septicemia. — Septicemia  is  a  blood  or 
general  condition  characterized  by  (a)  bacteriemia  and  toxemia;  (b)  certain 
clinical  phenomena;  and  (c)  certain  post-mortem  findings.  Bacteria  cannot 
always  be  obtained  from  the  blood,  but  their  presence  therein  is  assumed  if 
the  other  conditions  are  in  evidence.  When  metastatic  lesions  are  present  we 
have  a  special  clinical  or  anatomical  variety,  but  metastases  do  not  necessarily 
occur.  Endocarditis  when  it  develops  is  not  usually  counted  as  a  metastasis, 
but  a  complication  which  is  itself  a  cause  of  metastatic  foci. 

In  non-metastatic  septicemia  the  post-mortem  lesions  are  slight,  and  con- 
fined to  cloudy  swelling  of  the  kidneys,  liver,  and  heart,  with  an  enlarged  and 
relaxed  spleen.  Clinically  septicemia  may  be  ushered  in  with  a  chill,  followed 
by  high  fever  of  remittent  type ;  or  it  may  develop  in  a  most  insidious  manner, 
the  temperature  rising  gradually.  The  pulse-rate  varies  with  the  temperature 
and  may  reach  150.  There  are  great  prostration  and  a  cyanotic  pallor.  The 
disease  may  be  malignant  from  the  start,  destroying  life  in  a  few  days  or  a 
fortnight  or  it  may  extend  over  many  weeks.  Clinically  it  is  usually  accom- 
panied by  severe  focal  affections.  From  these  primary  foci  the  bacteria  and 
toxins  continue  to  enter  the  blood  by  the  lymphatic  route ;  hence  the  course  and 
prognosis  depend  somewhat  on  the  progress  of  the  primary  lesion.  In  a  certain 
proportion  of  cases  endocarditis  develops,  while  in  others  true  metastases  occur. 
These  elements  also  exert  great  influence  over  the  ultimate  outcome  of  the 
disease. 

Sepsis  with  endocarditis  and  metastatic  sepsis  do  not  differ  from  those  affec- 
tions in  non-puerperal  subjects  and  need  not  be  dwelt  upon. 

In  the  narrower  sense  of  the  term,  puerperal  sepsis  is  due  to  the  ordinary 
pus-exciters,  principally  the  streptococcus.  Sepsis  due  to  the  staphylococcus, 
bacillus  coli,  pneumococcus,  etc.,  also  occurs,  as  well  as  does  mixed  infection. 
Septicemia  of  a  character  similar  to  the  ordinary  streptococcus  type  might  be 
associated  with  puerperal  scarlatina  and  erysipelas ;  also  with  gonorrhea. 

Septicemia  in  the  wider  sense  of  the  term,  not  due  to  the  familiar  pyogenic 
bacteria,  may  occur  in  the  puerperium.  Here  would  belong  typhoid  fever  and 
acute  general  tuberculosis. 

2.  Pyemia. — Pyemia  is  merely  a  form  of  septicemia  which  follows  phlebitis 
and  suppuration  of  thrombi.  The  peculiarity  of  the  primary  lesion  leads  to 
clinical  and  anatomical  peculiarities,  for  large  amounts  of  bacterial  toxins  have 
ready  and  repeated  access  to  the  blood,  as  do  likewise  pus  corpuscles  and  portions 
of  infected  thrombi.  In  ordinary  septicemia,  when  pus  enters  the  blood  it  is 
usually  as  a  result  of  secondary  ulcerative  endocarditis;  while  in  pyemia,  the 
pus  proceeds  directly  from  the  infected  uterine  sinuses.  Ulcerative  endocarditis 
is  also  very  common  in  pyemia.  Generally  speaking,  no  absolute  distinction  can 
be  made  between  the  blood-states  in  p3^emia  and  septicemia. 


742  PATHOLOGICAL  PUERPERIUM. 

Pyemia,  like  septicemia,  may  run  a  fulminant  or  a  subacute  course.  In  the 
first  place  the  large  amount  of  toxins  which  enter  the  blood  gives  the  disease 
the  character  of  a  severe  toxemia  which  may  be  fatal  before  metastases  are 
in  evidence;  in  the  subacute  form,  toxemia  is  less  marked  and  metastatic  com- 
plications may  succeed  one  another. 

As  a  rule,  pyemia  is  characterized  by  repeated  chills,  which  may  occur  daily, 
sometimes  to  the  extent  of  several  in  a  day.  The  fever  curve  is  irregular  and 
either  intermittent  or  remittent.  In  acute  cases  the  symptoms  resemble  those 
of  acute  septicemia;  in  fact  there  is  no  essential  difference  between  the  two 
states.     (See  Metastatic  Focal  Affections.) 

3.  Septicopyemia. — This  term  is  sometimes  used  to  denote  a  special  blood- 
state,  which  is  said  to  be  inevitably  fatal,  but  it  does  not  appear  just  what  is 
meant  by  the  term  septicopyemia.  In  former  years  it  was  evidently  used 
as  an  equivalent  for  pyemia.  Following  modem  terminology  we  shall  restrict 
the  term  to  cases  in  which  the  blood  is  infected  by  the  venous  and  lymphatic 
routes  combined.  Thus  Trendelenburg  found  that  in  forty-three  fatal  cases 
of  puerperal  fever  there  were  eighteen  cases  of  septicemia,  twenty-one  cases  of 
pyemia,  and  four  of  combined  lymphatic  and  venous  infection  (septicopyemia). 
Clinically  such  a  condition  may  be  regarded  as  a  pyemia. 

V.  Sapremic  Sepsis,  including  Gas  Sepsis. — Sepsis  representing  an  association 
of  bacteriemia  and  toxemia,  the  term  sapremic  sepsis  may  be  used  to  denote 
several  conditions.  Thus,  in  simple  sapremia  of  a  fulminating  type,  the  sapro- 
phytes may  be  found  in  the  blood  during  life,  as  shown  by  Lenhartz.  Ordinarily, 
however,  the  expression  sapremic  sepsis  would  imply  a  mixed  or  associate  condi- 
tion, in  which  ordinary  septicemia  or  pyemia  is  associated  with  sapremia  from 
putrefaction  of  the  uterine  contents  and  perhaps  of  the  endometrium  itself.  Such 
a  condition  is  overwhelmingly  toxic,  because  the  blood  contains  both  bacterial 
toxins  and  the  products  of  putrefaction.  It  represents  a  severe  and  fulminant 
type  of  disease,  and  one  which  should  be  essentially  malignant.  Recovery  may 
occur,  however;  Lenhartz's  case  No.  48  represents  a  sapremic  sepsis  in  which 
sapremia  was  associated  with  bacillus  coli  bacteriemia.  The  bacterium  disap- 
peared from  the  blood  as  the  case  progressed  to  recovery.  In  such  cases  of  mixed 
infection  removal  of  putrescible  material  from  the  uterus  is  not  necessarily  fol- 
lowed by  improvement  in  the  lochial  discharge,  which  may  remain  offensive  for 
days,  signifying  that  the  endometrium  itself  is  the  seat  of  putrescence.  Doubtless 
this  severe  involveraent  of  the  endometrium — mixed  putrid  and  pyogenic  endome- 
tritis— is  responsible  for  the  associated  implication  of  the  blood.  Another  still 
more  formidable  type  of  sapremic  sepsis  is  the  so-called  "gas  sepsis" — a  condi- 
tion which  is  rare  and  not  fully  understood.  It  is  known  that  most  of  the 
saprophytes  which  attack  the  tissues  after  death,  or  gangrenous  tissue  during 
life,  generate  gases  which  may  or  may  not  be  fetid.  Some  saprophytes,  such  as 
the  bacillus  aerogenes  capsulatus,  and  bacillus  phlegmones  emphysematosae, 
appear  to  be  able  to  attack  living  tissues  and  form  gas.  But  the  so-called 
tympania  uteri  may  be  due  to  a  variety  of  causes,  and  the  part  played  by  bacteria 
is  not  well  defined.  In  many  cases  which  end  fatally,  it  is  not  easy  to  decide 
whether  the  gas-forming  bacteria  have  attacked  the  tissues  before  or  after  d-eath. 
It  is  admitted,  however,  that  in  some  of  the  severest  forms  of  putrid  or  mixed 
endometritis,  gas-forming  saprophytes  may  attack  the  uterus  during  life  and 
also  set  up  a  gas-bacteriemia  and  gas-forming  metastatic  lesions.  In  most  of 
such  cases  ordinary  septicemia  or  pyemia  coexists. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.   743 


General  Conditions  with  Anomalies  of  Temperature 

VI.  Simple  Hyperthermia. — This  condition,  also  known  as  pseudo-fever,  con- 
sists, as  its  name  implies,  of  a  simple  elevation  of  temperature  without  any  of 
the  collateral  pnenomena  of  true  fever.  It  has  been  noticed  under  a  variety 
of  circumstances,  and  is  due  apparently  to  a  variety  of  causes.  Slight  elevation 
of  temperature  may  follow  a  hot  bath.  Rise  of  temperature  has  been  produced 
by  suggestion,  and  by  mere  nervous  excitement.  The  thermal  center  is  doubtless 
under  the  influence  of  emotional  and  reflex  excitation  in  subjects  with  nervous 
instability.  When  we  remember  that  the  latter  condition  is  common  in  the 
pregnant  woman  and  can  hardly  disappear  at  once  after  delivery,  it  should  not 
surprise  us  to  see  paradoxical  elevations  of  temperature  in  the  puerpera.  Not 
only  do  we  find  simple  hyperthermia  in  the  presence  of  nervous  excitement 
and  physical  discomfort  (constipation) ;  but  even  in  sapremia  up  to  a  certain 
degree,  rise  of  temperature  is  not  attended  with  collateral  evidences  of  fever. 
Simple  hyperthermia  is  not  of  long  duration,  as  a  rule. 

Caution. — It  is  to  be  hoped  that  the  student  will  not  infer  from  the  list 
of  possible  causes  of  fever  which  I  mention  that  any  of  them,  except  perhaps 
the  constipation  and  reflex  influences,  are  at  all  common  during  the  puerperium. 
The  undoubted  possibility  of  their  occurrence,  however,  makes  it  incumbent 
upon  the  physician  in  every  doubtful  case  carefully  to  search  for  the  evidences 
of  acute  or  chronic  disease,  just  as  he  would  in  any  patient  and  at  any  time. 
Typhoid  fever  and  malaria,  especially  the  latter,  have  been  convenient  names 
by  which  to  designate  the  results  of  improper  management  of  labor  and  the 
puerperium.  When  the  practitioner  realizes  that  he  should  either  wear  sterile 
rubber  gloves  or  disinfect  his  hands  and  arms  as  carefully  for  a  vaginal  exam- 
ination as  for  a  laparotomy;  that  vaginal  examinations  should  be  as  infrequent 
as  possible,  and  should  be  preceded  by  careful  cleansing  of  the  vulva  and 
that  all  unnecessary  manipulations  should  be  avoided  after  delivery, — he  will 
find  that  fever,  except  transient  rises  of  temperature  from  constipation  and 
reflex  causes,  will  be  of  the  rarest  occurrence,  and  that  he  will  seldom  be  called 
upon  to  make  the  differential  diagnosis  between  puerperal  sepsis  and  other 
febrile  affections. 

Some  difficulty  arises  in  classifying  the  causes  of  pseudo-fever,  since  in 
some  cases  the  fever  is  of  reflex  origin,  while  in  others  it  is  not  so  or  only 
in  part  reflex  in  character.  I  believe,  however,  that  the  following  arrange- 
ment will  be  of  service  in  enabling  the  student  to  recall  and  to  differentiate  tlie 
different  kinds  of  fever. 

I.  Constipation. — That  constipation  may  cause  a  rise  of  temperature  during 
the  puerperium  is  a  matter  of  everyday  experience  (Fig.  959).  Doubtless  this 
fever  is  partly  reflex  in  character  from  the  distention  of  the  bowel  and 
consequent  local  discomfort,  but  it  is  also  toxic,  as  shown  by  the  head- 
ache and  general  malaise  which  accompany  it.  This  condition  was  recog- 
nized and  described  by  Oilman,  Schroeder,  Roswell  Park,  and  others,  as  the 
result  of  the  absorption  of  products  of  decomposition.  It  is  not  peculiar  to 
the  puerperium,  but  there  is,  at  this  time,  a  special  predisposition  to  it,  on 
account  of  the  accumulation  of  feces  in  the  later  weeks  of  pregnancy  and 
the  sluggish  intestinal  action  during  the  puerperium,  the  causes  of  which  have 
already  been  considered.  It  is  also  a  well-known  fact  that  a  prolonged  re- 
cumbent posture  predisposes  to  obstinate  constipation.  The  treatment  consists  in 
the  proper  regulation  of  the  bowels  during  the  later  weeks  of  pregnancy,  by  atten- 
tion to  the  diet,  and  the  administration  of  a  laxative  on  the  evening  of  the  second 


744  PATHOLOGICAL  PUERPERIUM. 

or  morning  of  the  third  puerperal  day,  followed,  if  necessary,  by  an  enema. 
(See  Management  of  the  Puerperium  and  Diet  of  the  Puerperal  Woman, 
pages  688  to  698.)  In  the  presence  of  fever  or  headache,  reasonably  attribu- 
table to  constipation,  the  prompt  administration  of  a  saline  cathartic  is  in- 
dicated. It  is  wise,  however,  not  to  wait  for  the  action  of  a  cathartic,  but 
to  give  at  once  a  copious  enema  of  soapsuds.  Subsequent  attention  to  diet 
is  important. 

2,  Hyperthermia  from  Reflex  Irritation. — That  a  sharp  but  usually  transient 
rise  of  temperature  ma}^  be  produced  by  reflex  irritation  is  a  fact  with  which  the 
obstetrician  soon  becomes  familiar  (Fig.  961).  In  this  case  the  fever  is,  without 
doubt,  due  to  the  effect  of  the  exciting  cause  upon  the  nervous  system,  but 
the  modus  operandi  is  largely  a  matter  of  speculation,  and  need  not  be  discussed 
here.  It  is  a  matter  of  clinical  experience,  however,  that  the  circumstances 
attendant  upon  pregnancy,  labor,  and  the  puerperium,  tend,  especially  in  patients 
of  the  neurotic  type,  to  an  exaggeration  of  reflex  nervous  excitability.  Fever 
of  reflex  origin  is  usually  to  be  traced  to  some  source  of  pain  or  discomfort 
purely  physical  in  character,  and  not  of  infectious  origin.  The  most  frequent 
source  of  trouble  in  this  respect  is  overdistention  of  the  breasts  with  milk. 
I.  Mammary  Irritation:  Among  the  sources  of  reflex  irritation,  distention 
of  the  breasts  is  perhaps  the  most  frequent  and  important.  The  so-called 
"milk  fever"  of  the  older  writers  has  already  been  alluded  to,  and  is  now  re- 
garded as  obsolete,  but  it  is  nevertheless  true  that  the  extreme  and  painful 
distention  which  sometimes  occurs  with  the  establishment  of  the  milk  secretion 
may,  and  frequently  does,  cause  a  considerable  rise  of  temperature,  which 
promptly  subsides  with  the  disappearance  of  the  cause  (Fig.  961).  Diagnosis : 
Fever  resulting  from  overdistention  of  the  breasts  is  to  be  distinguished  from 
septic  infection  of  the  genital  tract  by  determining  the  fact  of  overdistention 
of  the  breasts  and  its  resulting  discomfort,  by  the  fact  that  the  fever  is  of  short 
duration,  disappearing  with  the  removal  of  the  cause.  The  various  kinds  of 
infection  may  be  excluded  by  the  methods  described  in  connection  with  the 
diagnosis  of  the  different  varieties  of  sepsis,  but  this  will  not  usually  be  necessary. 
Especial  care  should,  however,  be  taken  not  to  mistake  a  beginning  mastitis 
for  overdistention  of  the  breast,  since  the  treatment  of  these  conditions  is 
radically  different,  and  a  mistake  is  likely  to  result  disastrously  for  the  patient. 
The  diagnosis  of  mastitis  is  considered  elsewhere  (page  762).  As  regards  treat- 
ment, the  child  should  be  put  to  the  breast  and  the  surplus  amount  of  milk 
removed,  if  necessary  by  the  breast-pump,  or  better  by  gentle  massage  under 
hot  stupes;  but  all  rough  handling  of  the  breast  must  be  avoided.  If  necessary, 
a  saline  cathartic  may  be  given  and  the  amount  of  fluids,  especially  milk,  limited 
for  a  time.  A  properly  applied  breast  bandage  may  be  a  source  of  comfort 
to  the  patient.  Abscess  of  the  breast  is  considered  elsewhere  as  a  form  of 
local  sepsis.  2.  Sore  Nipples:  The  pain  attending  a  cracked  or  fissured 
nipple,  especially  during  nursing,  may  cause  a  transient  rise  of  temperature, 
although  in  such  a  case  we  would  ordinarily  suspect  infection  through  the 
nipple  (Fig.  971).  3.  Rupture  of  the  Uterus:  Among  the  causes  of  fever 
which  may  be  regarded  as  purely  reflex  in  character,  may  be  noted  the  rise 
of  temperature  which  may  almost  immediately  follow  uterine  rupture.  Al- 
though fever  due  to  septic  peritonitis  and  other  infectious  conditions  may, 
of  course,  follow  later,  it  seems  reasonable  to  ascribe  the  first  rise  of  temperature 
to  reflex  irritation.  4.  Retrodisplacements  of  the  Puerperal  Uterus: 
A  rise  of  temperature  due  to  this  cause  and  promptly  disappearing  after  replace- 
ment I  have  observed  as  late  as  the  fourth  week. 


MORBID  CONDITIONS  ORIGINATING  IN  THE  PUERPERIUM.   745 

It  is  obvious  that  the  hst  of  possible  causes  of  non-septic  fever  may  be 
indefinitely  extended.  Colic,  the  peristaltic  action  evoked  by  cathartics,  the 
discomfort  attending  the  passage  of  hard  fecal  masses,  or  the  prolonged  retention 
of  urine,  might  cause,  in  patients  of  the  neurotic  type,  a  fever,  disappearing 
promptly  with  the  removal  of  the  cause.  Exposure  to  cold  is  an  occasional 
cause,  and  I  have  observed  fever,  excitement,  and  neurotic  symptoms  late 
in  the  puerperium  from  the  presence  of  a  tapeworm,  which  was  subsequently 
secured. 

3.  Hyperthermia  from  Neurotic  Conditions. — The  possible  occurrence  of  fever 
as  the  result  of  organic  nervous  disease  has  already  been  noted.     It  remains  to 


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Ninth    Day    of    the     Puee- 


notice  the  role  played  by  functional  neuroses  in  the  production  of  fever  during 
the  puerperium.  Emotional  Excitement:  This  frequently  causes  a  tran- 
sient rise  of  temperature.  Fright,  grief,  anger,  excessive  annoyance  from  any 
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absence  of  the  general   symptoms  due  to  septic   infection.     The  treatment  is 


746 


PATHOLOGICAL  PUERPERIUM. 


obvious.  During  the  puerperal  period  all  visitors  except  the  patient's  mother 
or  husband  should  be  excluded,  and  every  source  of  annoyance  and  excitement 
eliminated  as  far  as  possible.  The  importance  of  securing  for  the  patient  a 
sufficient  amount  of  undisturbed  sleep  has  been  referred  to  in  connection  with 
the  management  of  the  puerperium,  and  cannot  be  overestimated.  In  cases 
of  hysteria,  in  addition  to  measures  adapted  to  the  morale  and  surroundings, 
the  bromides  and  other  nerve  sedatives  will  be  of  service. 

VII.  True  Fever. — True  fever  is  characterized  by  a  number  of  phenomena, 
of  which  hyperthermia  is  the  chief.  It  begins  in  general  with  a  precursory 
hypothermia,  sometimes  expressed  by  chilliness  or  rigors,  and  after  its  establish- 


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by  massage  through  hot  stupes. 


ment  pursues  a  certain  course  with  intermissions  or  remissions.  In  most  cases 
it  is  due  to  a  toxic  principle  in  the  blood,  which  is  akin  to  the  albumoses.  An 
albumose-reaction  can  be  obtained  from  febrile  urine  in  the  majority  of  cases. 
This  substance,  while  affecting  the  heat  center,  also  acts  upon  the  vasomotor 
center  as  well,  so  that  fever  is  accompanied  by  circulatory  phenomena,  chiefly 
local  congestions.  Since  true  fever  is  due  to  the  action  of  a  toxin,  we  find  it 
associated  as  a  rule  with  malaise,  headache,  pain  in  the  limbs,  anorexia  and 
other  evidences  of  toxemia.  The  pulse-rate  increases,  as  a  rule,  with  the  tem- 
perature. A  certain  group  of  symptoms  is  caused  by  the  persistent  high  tem- 
perature and  increased  interchange  of  gases,  as  thirst,  dryness  of  the  mouth. 


CLINICAL   TYPES  OF  PUERPERAL  MORBIDITY.  747 

scanty  urine,  etc.  In  the  puerperium  it  is  important  to  discriminate  between 
mere  hyperthermia  and  true  fever,  for  the  former,  as  a  rule,  requires  no  inter- 
vention directed  to  the  uterus.  The  fever  of  sapremia,  toxemia,  septicemia,  etc., 
is  essentially  one  and  the  same,  being  due  either  to  products  of  putrefaction  or 
bacterial  toxins,  both  classes  of  substances  being  akin  to  toxalbumoses. 

VIII.  Hypothermia. — Hyperthermia  and  fever  do  not  necessarily  accompany 
the  blood-intoxications  and  infections  of  puerperal  morbidity.  Instead  we 
may  encounter  hypothermia,  under  which  term  we  may,  for  simplicity's  sake, 
include  normal  temperatures  when  present  in  severe  systemic  affections.  Len- 
hartz  states  that  hypothermia  is  known  to  occur  under  three  conditions,  i. 
Severe  collapse  or  adynamia  such  as  complicates  perforation  of  the  uterus  and 
peritoneum  (as  an  accident  of  forceps  delivery).  He  relates  a  typical  case  in 
which  a  woman  lived  for  seven  days  without  rise  of  temperature,  a  feeble  eleva- 
tion occurring  just  before  death.  2.  Subfebrile  periods  in  ordinary  cases  of 
sepsis.  These  occur  under  various  circumstances.  Thus  in  a  case  of  what 
proved  to  be  combined  putrid  and  infectious  endometritis,  emptying  the  uterus 
resulted  in  four  days  of  normal  temperature,  after  which  pyogenic  endometritis 
asserted  itself  with  fatal  sepsis.  When  pyemia  leads  to  secondary  suppurative 
foci  in  the  joints,  empyema,  etc.,  evacuation  of  the  pus  may  be  followed  for 
a  time  by  normal  or  subnormal  temperature.  3.  Terminal  hypothermia.  This 
phenomenon  is  sometimes  seen  just  before  death  in  severe  cases  of  sepsis  or 
pyemia. 

(D)  CLINICAL  TYPES  OF  PUERPERAL  MORBIDITY. 

Introduction. — Without  a  definite  understanding  of  the  various  focal  affec- 
tions and  blood  conditions,  it  is  impossible  to  understand  the  clinical  pictures 
which  puerperal  morbidity  may  assume.  The  number  of  these  conditions  is 
very  large,  although  they  readily  fall  into  certain  categories.  Thus  we  may 
have  certain  local  lesions  with  little  or  no  general  reaction,  and  general  sepsis 
with  but  little  local  disturbance.  We  may  have  local  putrefaction  of  dead 
tissue  associated  with  sapremia;  local  suppuration  (abscess)  with  toxemia  (fever 
of  suppuration);  local  inflammation  with  bacterio-toxemia ;  metrophlebitis  with 
so-called  pyemia;  various  combinations  of  the  preceding,  etc. 

The  General  Symptoms  of  Puerperal  Infection. — There  are  certain  symptoms 
common  to  most  cases.  The  most  prominent  of  these  is  fever.  An  elevation 
of  temperature,  commonly  occurring  about  the  third  day,  is  usually  the  first 
sign  that  attracts  attention.  The  pulse  is  increased  in  frequency,  and  when 
the  increase  is  not  in  proportion  to  the  amount  of  fever,  we  have  a  valuable 
diagnostic  symptom.  In  puerperal  sepsis  the  pulse  ratio  is  greater  than  with 
fever  due  to  other  causes.  Liebermeister  *  gives  the  pulse-rates  which  should 
result  from  corresponding  temperature  markings:  Temperature  98.6°  F.,  pulse- 
rate  78;  temperature  100.4°  F-.  pulse-rate  88;  temperature  102  2*  F.,  pulse-rate 
Q7;  temperature  104°  F.,  pulse-rate  105;  temperature  105°  F.,  pulse-rate  109; 
temperature  107°  F.,  pulse-rate  121.  A  chill  or  chilly  sensation  may  be  present, 
but  is  frequently  absent,  especially  in  the  milder  types  of  infection.  It  may, 
however,  be  present  in  any  variety  of  sepsis,  and  is  not  necessarily  indicative  of 
metastasis,  as  it  was  at  one  time  thought.  Pain  and  tenderness  in  the  pelvis  are 
not  constant  symptoms,  and  the  same  may  be  said  of  distention  of  the  abdomen 
due  to  paralysis  and  consequent  relaxation  of  the  intestines,  of  nausea  and 
vomiting,  a  coated  tongue,  constipation  or  diarrhea,  special  changes  in  the 

*  "  Vorlesungen  iiber  specielle  Pathologic  und  Therapie,"  Band  in. 


748  PATHOLOGICAL  PUERPERIUM. 

urine,  sleeplessness,  and  delirium.  Headache  is  a  prominent  symptom,  as  are 
disturbances  in  the  process  of  involution,  shown  by  a  soft,  flabby  uterus. 
Diminution  in  the  quantity  of  the  lochia,  especially  for  twenty-four  or  forty- 
eight  hours  at  the  outset  of  the  attack,  is  quite  constant,  but  a  marked  foul 
odor  to  the  lochia,  except  in  cases  of  retained  secundines,  is  not  necessarily 
present.     Foul  odor  is  often  absent  in  the  severest  types  of  puerperal  sepsis. 

I  would  give  the  following  symptoms  as  most  pathognomonic  of  the  various 
types  of  puerperal  sepsis,  aside  from  a  bacteriological  examination  of  the  blood 
and  the  secretions  of  the  genital  tract:  (i)  Fever;  (2)  increase  in  pulse-rate  out 
of  proportion  to  the  amount  of  fever;  (3)  sensitiveness  of  the  pelvic  organs 
to  pressure;  (4)  disturbed  involution;  (5)  persistent  diminution  in  the  amount 
of  the  lochia.  When  the  symptoms  begin  a  few  hours  after  labor,  they  are 
probably  due  to  infection  before  or  during  labor.  If  no  symptoms  appear 
by  the  end  of  the  fifth  day,  the  patient  may  usually  be  regarded  as 
out  of  danger  from  sepsis.  There  are  exceptions  to  this  rule,  however,  as 
will  presently  be  noted.  The  student  should  remember  that  while  in  the 
majority  of  cases  the  infection  starts  from  the  vagina  or  cervix,  the  symptoms 
first  noticed  are  usually  those  of  an  endometritis. 

1.  Purely  Local  and  General  Conditions. — Extension  of  an  aseptic  thrombus 
from  the  uterine  to  the  pelvic  veins,  producing  the  so-called  benign  form  of  milk- 
leg,  may  be  mentioned  as  an  uncomplicated  local  affection.  The  so-called 
cryptogenous  sepsis  without  evidence  of  local  lesion  represents  an  uncomplicated 
general  state.  Simple  hyperthermia,  from  neurotic  or  reflex  conditions,  may 
occur  without  evidences  of  local  or  general  conditions.  Mild  sapremia  or 
toxemia  (bacterial)  may  accompany  an  ordinary  puerperium  (so-called  resorp- 
tion or  "one-day"  fever). 

2.  Marked  sapiemia  occurs  as  a  result  of  much  putrescible  material  in  the 
uterus — as  in  lochiometria,  putrefaction  of  retained  or  adherent  placenta,  putrid 
abortion,  missed  labor  with  fetal  putrefaction,  gangrene  of  uterus,  etc.  When- 
ever it  is  possible  to  empty  the  uterus  in  time  the  severe  symptoms  usually 
subside. 

3.  Marked  bacterial  toxemia  (without  sepsis),  corresponding  to  ordinary 
surgical  fever,  occurs  whenever  pyogenic  bacteria  attack  the  birth-tract,  para- 
metria, tubes,  pelvic  peritoneum,  etc.  As  a  rule,  the  degree  of  toxemia  varies 
with  the  amount  of  pus-formation.  Bacteria  may  reach  the  blood  in  small 
numbers  and  yet  sepsis  need  not  result.  As  long  as  the  suppurative  focus  is 
surrounded  by  a  barrier  of  granulation  tissue,  sepsis  is  prevented  and  toxemia 
held  in  check.  If  general  peritonitis  develops  the  toxemia  is  sufficient  to  cause 
death  (malignant  toxemia). 

4.  Simple  septicemia,  pyemia,  sapremic  sepsis,  are  conditions  in  which  bac- 
teria enter  the  blood  in  large  numbers  along  with  toxins  ;  yet  the  majority  of 
these  conditions  is  not  due  so  much  to  the  bacteria  as  to  the  degree  of  toxemia, 
which  is  naturally  much  greater  when  the  insufficiency  of  the  leucocyte  barrier 
allows  a  wholesale  absorption.  Hence,  sepsis  without  metastases  is  practically 
a  malignant  toxemia. 

5.  Metastatic  septicemia  and  pyemia  represent  not  only  states  of  intense 
toxemia,  but  the  occurrence  of  metastatic  deposits  in  vital  organs  gives  these 
conditions  a  hopeless  character.  In  septicemia  proper,  metastases  are  the 
results  of  septic  endocarditis;  while  in  pyemia,  which  results  from  metrophlebitis, 
metastases  to  the  various  viscera  occur  without  the  intermediation  of  the 
cardiac  lesion. 

At  the  present  moment,  the  belief  that  the  syncytial  cells  of  the  placenta 


TREATMENT  OF  PUERPERAL  INFECTION.  749 

play  a  principal  role  in  the  toxemia  of  pregnancy,  appears  to  be  gaining  ground, 
although  there  is  much  diversity  as  to  the  manner  in  which  the  results  are 
produced.  From  one  point  of  view  these  cells  cause  embolism  in  the  liver  and 
kidneys,  thereby  setting  up  the  characteristic  lesions  of  these  organs.  From 
another  point,  the  cells  are  believed  to  secrete  a  poisonous  substance  which 
attacks  the  predisposed  organs.  These  views  are  not  incompatible  with  the 
theory  of  hepatic  toxemia. 


TREATMENT  OF  PUERPERAL  INFECTION. 
I.     PREVENTIVE  TREATMENT. 

This  has  been  largely  discussed  in  connection  with  the  management  of 
labor,  and  it  cannot  too  often  be  repeated  that  when  the  management  of  normal 
labor  is  regarded  as  very  largely  identical  with  the  preventive  treatment  of 
puerperal  infection,  the  latter  will  be  of  the  rarest  occurrence.  I  sum  up 
the  preventive  treatment  of  puerperal  sepsis  under  four  heads:  (i)  General 
hygienic  measures.  (2)  Asepsis  of  patient,  physician,  and  accessories.  (3) 
Limitation  of  internal  examinations  and  manipulations.  (4)  Antistrepto- 
coccic serum. 

(i)  Hygienic  Measures. — Under  this  head  is  to  be  considered  everything 
which  tends  to  fortify  the  system  against  disease  in  general.  Good  blood 
is  the  best  of  germicides,  hence  the  importance  of  good  hygiene  during  preg- 
nancy; an  out-of-door  life,  good  diet,  freedom  as  far  as  possible  from  sources  of 
worr}^  and  care.  The  correction  of  anemia  by  iron  and  other  tonics,  the  treat- 
ment of  any  constitutional  dyscrasia,  should  be  carefully  attended  to  in  order 
to  prepare  the  patient  against  the  inroads  of  septic  infection.  Under  the  same 
heading  come  certain  precautions  already  discussed  elsewhere;  e.  g.,  the  selection 
of  a  sunny  and  commodious  lying-in  chamber,  as  far  as  possible  removed  from 
toilets,  sinks,  and  plumbing,  and  securing  good  ventilation.  All  these  precau- 
tions should  be  regarded  as  important  because  they  prepare  the  patient  to 
resist  infecting  agents;  but  it  should  not  be  forgotten  that  all  the  agents  thus 
combated  do  not  of  themselves  act  as  the  immediate  causes  of  infection.  Nor 
should  the  physician  forget,  in  his  attention  to  such  details,  that  the  actual  cause 
of  puerperal  infection  is  contact  of  wounds  in  the  birth  canal  with  an  infected 
agent. 

(2)  Asepsis  of  Patient,  Physician,  and  Accessories. — The  patient  (see  Manage- 
ment of  Labor,  page  472):  The  arrangement  of  the  vulval  pads  and  the  subse- 
quent cleaning  of  the  external  genitals  have  already  been  described  in  connection 
with  the  management  of  the  puerperium  (page  688).  The  physician:  A  physi- 
cian who  is  dressing  suppurating  wounds,  attending  cases  of  erysipelas,  scarlet 
fever,  diphtheria,  or  other  cases  of  infectious  or  contagious  diseases,  should 
not  attend  obstetric  cases  if  he  can  help  it.  If  he  is  obliged  to  do  so,  he  should 
take  a  full  bath,  change  his  clothing,  disinfect  his  hands  and  arms  with  special 
care,  and  make  no  internal  examinations  that  are  not  imperatively  necessar}', 
and  then  only  with  his  hands  encased  in  sterile  rubber  gloves.  The  method  of  hand 
disinfection  has  been  described  (page  150).  It  is  needless  to  say  that  any 
man  who  practises  obstetrics  should  himself  be  free  from  infectious  or  conta- 
gious diseases;  he  should  be  cleanly  as  to  his  habits,  should  bathe  fre- 
quently, should  wear  clean  clothing,  should  keep  his  nails  trimmed  short  and 
carefully  cleaned,  and  should  be  particular  even  to  fastidiousness  about  the 
care  of  his  hands.  The  use  of  a  sterile  operating  gown  or  duck  suit  and  of 
sterile   rubber   gloves   is  an    additional   safeguard  (page    151).      The  nurse:  As 


750  PATHOLOGICAL  PUERPERIUM. 

already  stated,  she  should  be  free  from  any  contagious  or  infectious  disease 
especially  suppurative  coryza  or  skin  disease,  nor  should  she  recently  have 
attended  a  case  of  infectious  or  contagious  disease.  She  should  also  have 
had  a  full  bath  and  change  of  clothing,  paying  special  attention  to  the  hair, 
which  should  be  well  washed  with  soap  and  water,  then  with  plain  water,  and 
then  with  a  bichloride  solution  (i  :  10,000).  She  should  be  expressly  forbidden 
to  give  douches  or  practise  any  internal  manipulations  while  cleansing  the 
external  genitals.  Instruments  and  water  used:  All  instruments  or  other  appli- 
ances which  are  to  come  in  contact  with  any  part  of  the  parturient  tract  should 
first  be  thoroughly  scrubbed  with  green  soap  and  water,  especial  attention  being 
paid  to  any  cracks  or  crevices,  and  then  boiled  for  not  less  than  twenty  minutes. 
They  should  then  be  removed  by  an  aseptic  instrument  and  kept  in  a  solution 
of  carbolic  acid  or  lysol  until  needed,  or,  better,  used  directly  from  the  boiler 
or  sterilizer.  All  instruments  which  cannot  thus  be  sterilized  should  be  avoided. 
Catheters  and  douche  tubes  should  be  of  glass  or  metal,  preferably  glass.  If  it 
becomes  necessary  to  use  a  Barnes  bag,  a  gum  catheter,  or  similar  appliance,  it 
should  first  be  thoroughly  washed  with  green  soap  and  water  and  then  sterilized 
by  boiling  or  by  steam  under  pressure.  All  water  used  for  immersing  instru- 
ments, washing  the  external  genitals,  and  giving  douches  should  first  be  boiled. 

(3)  Limitation  of  Internal  Examinations. — This  is  perhaps  the  most  im- 
portant precaution  of  all,  as  has  been  fully  stated  in  connection  with  the  manage- 
ment of  normal  labor  (page  476).  It  is  of  special  importance  if  the  physician 
has  recently  been  in  attendance  upon  any  case  of  infectious  or  contagious 
disease,  or  if  his  hands  have  been  contaminated  by  septic  discharges  of  any 
kind,  and  in  all  cases  during  and  after  the  third  stage  of  labor,  even  if  sterile 
rubber  gloves  are  used. 

It  is,  of  course,  true  that  in  many  cases  it  is  impossible  to  carry  out  all 
of  the  above  rules  in  practice.  Skilled  nursing  and  sterile  accessories  are  not 
always  available.  But  if  the  physician  will  but  remember  that  septic  contact 
is  the  one  source  of  infection,  if  he  insists  upon  and  personally  supervises  cleanli- 
ness and  antisepsis  of  the  external  genitals  and  their  immediate  surroundings, 
and  avoids  all  unnecessary  interference,  especially  after  delivery,  very  satis- 
factory results  may  be  secured  even  among  most  unfavorable  surroundings. 

(4)  Antistreptococcic  Serum. — The  preventive  power  of  Marmorek's  serum 
was  tested  by  Wallich  upon  383  women  who  bade  fair  to  have  a  septic  puer- 
perium  either  by  reason  of  certain  acts  of  exposure  or  accidents  of  delivery.  De- 
spite the  precaution,  56  developed  phenomena  of  infection.  Streptococci  have 
been  more  successfully  combated  without  than  with  the  aid  of  the  serum. 

2.     CURATIVE   TREATMENT. 

The  non-surgical  treatment  of  puerperal  infection  comprises,  at  the  present 
day,  supporting  measures,  antipyretics,  and  various  specifics  and  quasi-specific 
remedies  of  more  or  less  doubtful  utility,  such  as  Marmorek's  serum  and  Credo's 
silver  ointment. 

(i)  Supporting  Measures. — These  differ  in  nowise  from  the  same  class  of 
remedies  employed  in  the  treatment  of  typhoid  fever,  pneumonia,  etc.  The 
patient  receives  whisky  or  brandy  according  to  the  state  of  the  pulse,  with 
strychnin,  -^-j^  grain,  every  three  or  four  hours,  and  digitalis  as  necessary.  Quinin 
is  much  less  used  than  formerly,  although  individual  authorities  continue  to 
prescribe  it.  Diarrhea  should  not  be  checked,  and  many  authorities  even 
advocate  the  routine  use  of  aperients  in  puerperal  infection,  especially  calomel 
and  laxative  salts.     Vomiting  requires  cracked  ice  and  champagne.     In  order 


TREATMENT  OF  PUERPERAL  INFECTION.  751 

that  the  patient's  vitality  may  be  kept  at  the  highest  point,  it  is  necessary 
that  she  should  receive  a  plentiful  supply  of  nutritious  food.  Milk,  koumyss, 
broths,  eggs  beaten  up  with  milk  or  broths,  beef-juice,  panopeptone,  beef 
peptonoids,  and  so  on,  should  be  administered  in  as  large  quantities  as  the 
patient  can  assimilate.  It  is  well,  also,  to  try  the  effect  of  solid  food — e.  g., 
raw  oysters,  meat,  etc.  In  prolonged  cases  it  is  of  great  importance  to  a  patient 
suffering  from  sepsis  that  the  stomach  should  be  in  such  condition  as  to  retain 
an  abundant  supply  of  nutritious  food  and  stimulants,  which  is  a  cogent  reason 
for  not  giving  medicines  whose  utility  is  doubtful  and  which  may  derange 
that  organ.  Good  results  are  obtained  from  the  subcutaneous  injection  of  salt 
solution  in  large  quantities.  A  more  direct  method,  of  course,  is  that  of  venous 
infusion.  From  one  to  two  pints  may  be  injected.  (See  Part  X.)  Washing  out 
the  colon  by  means  of  decinormal  salt  solution  is  worthy  of  further  trial,  not  only 
upon  theoretical  grounds,  but  because  occasional  favorable  results  have  been  re- 
ported in  puerperal  as  well  as  non-puerperal  forms  of  sepsis.  Finally,  a  very 
valuable  remedy  in  these  cases  is  oxygen,  which  should  be  inhaled  in  large  quan- 
tities and  systematically.  The  use  of  ergot  to  promote  involution,  and  by  causing 
uterine  contraction  to  prevent  the  transmission  of  infection  through  the  lymph- 
atics, has  already  been  mentioned  and  constitutes  a  rational  method  of  treatment. 
I  am  inclined  to  believe  that  it  prevents  also  the  absorption  of  pathogenic  germs 
which  may  be  present  in  the  vagina.  The  absorbent  power  of  a  lax  uterus  is 
very  marked. 

(2)  Antipyretics. — Quinin,  phenacetin,  and  other  antipyretics  have  been 
advocated  by  various  observers.  In  a  process  like  acute  peritonitis,  which 
runs  a  rapid  course  and  in  which  death  is  due  to  other  causes  than  fever,  they 
are  of  little  or  no  service,  and  may  do  harm  by  causing  cardiac  depression  and 
disturbing  the  stomach.  In  prolonged  cases — i.  e.,  in  pyemia — they  are  some- 
times beneficial",  and  when  fever  is  attended  by  headache  they  may  afford  relief. 
Under  such  circumstances  they  should  be  given  tentatively  if  bad  effects  on 
the  heart  and  stomach  are  not  noticed.  If  the  coal-tar  derivatives  are  given, 
those  least  depressing  to  the  heart  should  be  selected,  and  it  is  well  to  give 
a  stimulant  at  the  same  time.  Hydrotherapy  offers  a  better  means  of  reducing 
fever  in  these  cases.  There  is  considerable  testimony  as  to  the  efficacy  of  the 
cold  bath,  and  if  it  is  not,  as  occasionally  happens,  too  depressing  to  the  patient, 
its  use  is  to  be  advised.  My  practice  is  to  rely  mainly  upon  the  wet  pack,  cold 
sponging,  and  the  abdominal  coil  as  antip3^retics.  For  local  inflammatory  ten- 
derness, whether  from  endometritis,  affections  of  the  parametrium,  or  general 
peritonitis,  the  intermittent  application  of  cold,  as  the  coil  or  ice-bag,  applied 
to  the  fundus,  is  usually  a  wise  precaution. 

(3)  Specific  Medication. — Antistreptococcic  serum:  Orrhotherapy  in  puerperal 
fever  is  still  on  trial.  While  many  have  abandoned  it,  others  continue  to 
employ  it.  It  is  necessary  to  exhibit  the  remedy  in  large  doses.  The  initial 
injection  should  be  0.7  oz.  (20  c.c),  while  the  total  daily  dose  should  be  2.1  oz. 
(60  c.c.)  in  desperate  cases.  In  one  class  of  cases  prompt  and  permanent 
recovery  appears  to  follow  the  treatment,  while  in  others  improvement  is  either 
wanting  or  may  be  only  temporary.  The  use  of  this  serum  is,  of  course,  irra- 
tional without  evidence  that  the  streptococcus  is  present  in  pure  culture.  In 
communities  where  bacteriological  tests  of  the  lochia  cannot  be  obtained  the 
serum  may  be  used  in  any  desperate  case  as  a  last  resort.  Crede's  ointment: 
This  preparation  of  silver,  which  was  introduced  in  1895,  as  a  general  remedy 
for  sepsis,  has  been  used  to  a  limited  extent  in  puerperal  infection.  As  appar- 
ently hopeless  cases  of  the  latter  may  suddenly  take  a  turn  for  the  better 


752  PATHOLOGICAL  PUERPERIUM. 

a  few  seemingly  successful  tests  of  a  remedy  prove  nothing.  On  account  of 
the  desperate  nature  of  the  disease,  however,  the  remedy  may  be  tried,  because 
it  is  harmless  and  can  be  exhibited  by  simple  inunction.  From  15  to  45  grains 
(2  to  3  gm.)  at  a  time  should  be  rubbed  into  the  internal  aspect  of  the  thighs 
once  or  twice  daily.  The  duration  of  the  inunction  should  be  twenty  minutes 
and  the  site  should  be  afterward  covered  with  rubber  tissue.*  Nuclein. 
Intravenous  injections  of  silver  salts.  Nuclein  has  been  proposed  to  produce 
an  artificial  leucocytosis.  From  a  limited  experience  I  have  failed  to  obtain 
any  marked  results.  I  am  compelled  to  make  the  same  statement  regarding 
the  intravenous  injection  of  the  silver  salts.  Mercurial  ointment:  This  is  still 
employed  in  some  European  clinics,  the  drug  being  pushed  to  the  point 
of  salivation.  By  most  authorities,  however,  this  method  is  justly  ignored. 
Abscess  of  fixation:  This  method  of  treatment,  which  is  evidently  the  same 
in  principle  as  that  of  the  seton  and  issue  formerly  used,  has  been  tried 
in  a  few  cases  of  puerperal  sepsis  with  apparent  benefit.  Professor  Fochier, 
of  Lyons,  who  is  the  advocate  of  this  mode  of  treatment,  states  that  in 
certain  cases  of  general  infection  we  see  the  patient's  condition  improve  suddenly 
and  materially  after  the  development  of  a  localized  suppuration.  This  he 
terms  "fixation  abscess."  In  cases  of  grave  sepsis  he  attempts  the  production 
of  an  artificial  abscess  by  injecting  turpentine  under  the  skin.  If  no  pus  forms, 
the  prognosis  is  hopeless.  If  a  large  abscess  can  be  formed  and  allowed  to 
increase  at  will  without  opening,  the  patient  undergoes  a  change  for  the  better. 
Intravenous  infusion  of  formaldehyde  solutions:  On  January  13,  1903,  Barrows, 
of  New  York,  reported  to  the  New  York  Obstetrical  Society  the  cure  of  a  severe 
case  of  puerperal  sepsis,  by  the  infusion  of  a  0.02  per  cent,  solution  of  formalin 
or  0.008  per  cent,  solution  of  formaldehyde  gas  into  a  vein  of  the  arm.  The 
remedy  has  since  been  used  with  varied  results  by  many.  Further  experience 
is  necessary  to  prove  its  usefulness.  Pryor's  Iodine  Treatment:  An  investigation 
of  the  uterine  discharges  and  the  contents  of  the  pelvic  cavity  in  cases  of  puer- 
peral sepsis  has  resulted  in  a  more  definite  idea  of  the  conditions  which  must  be 
treated.  W.  R.  Pry  or  f  has  operated  upon  thirty-seven  cases,  in  all  but 
one  of  which  streptococci,  generally  mixed  with  other  germs,  have  been 
found  in  the  uterine  discharge  and  in  all  the  cases  streptococci  were  found  in 
the  pelvic  cavity.  He  not  only  does  a  curettage  in  these  cases  and  packs  the 
cavity  with  iodoform  gauze,  but  he  also  does  a  posterior  section  of  the  vagina 
and  packs  the  cul-de-sac  full  of  iodoform  gauze..  The  results  have  been  uni- 
formly good,  and  on  the  third  day  the  germs  have  in  every  case  been  absent 
from  the  discharges.  This  excellent  result  is  attributed  to  the  local  iodism 
which  is  caused  by  the  action  of  the  exudates  upon  the  iodoform,  thus  setting 
iodine  free.  The  absorption  of  this  iodine  through  the  infected  lymphatics  is 
supposed  to  have  a  decided  and  beneficial  effect.  The  after-treatment  of  these 
cases  is  so  technical  and  consumes  so  much  time  that  it  would  be  difficult  to 
secure  for  it  a  very  general  adoption.  Attempts  are  now  being  made  to  secure 
this  local  and  general  iodism  by  more  easily  effected  means.  Ichthyol  Treatment: 
I  have  found  ichthyol  apparently  of  value  in  cases  in  which  after  clearing 
the  uterus  of  debris,  and  irrigating,  the  symptoms  still  persisted,  without  any 
marked  symptoms  of  extra-genital  infection.  After  the  final  irrigation  of  the 
uterus  with  a  saline  solution,  the  cavity  is  packed  with  gauze  soaked  in  a  sterile 

*  Unguentum  Cred6,  containing  15  per  cent,  of  coUargolum,  can  be  obtained  in  stiitable 
half-ounce  jars  from  Messrs.  Schering  and  Glatz,  58  Maiden  Lane,  New  York.  Care  must 
be  taken  that  an  inert  preparation  is  not  used. 

t"  N.  Y.  Med.  Jour  ,"  Aug.  22,  1903 


TREATMENT  OF  PUERPERAL  INFECTION.  753 

solution  of  ichthyol  in  water  (i  to  i).  It  has  also  been  proposed  to  inject  re- 
newal drams  of  a  50  per  cent,  solution  of  ichthyol  in  water  into  the  uterine 
cavity.  With  this  latter  method  I  have  had  no  experience.  I  usually  have 
the  ichthyol  gauze  in  the  uterus  for  twenty-four  hours,  remove  it,  irrigate  with 
a  saline  solution  and  repack.  In  certain  cases  to  avoid  too  much  disturbance 
of  the  patient  I  have  left  the  gauze  in  the  uterus  for  from  forty-eight  to 
seventy-two  hours.     The  uterus  should  not  be  tightly  packed. 

(4)  Endometritis. — For  various  reasons,  and  especially  because  nearly  every 
case  of  endometritis  may  be  regarded  as  containing  the  possibilities  of  a  mixed 
infection,  it  is  better  to  consider  the  treatment  of  all  the  forms  of  endometritis 
under  a  single  head.  The  best  authorities  are  now  inclined  to  conservatism  as 
regards  the  local  treatment  of  puerperal  endometritis,  the  weight  of  evidence 
tending  to  the  conclusion  that  active  intrauterine  treatment  indiscriminately 
applied,  in  the  presence  of  streptococcic  endometritis,  as  proved  by  a  bacterio- 
logical examination  of  the  uterine  secretion,  does  much  more  harm  than  good,  and 
my  experience  has  led  me  to  coincide  with  this  conclusion.  I  hold  the  opinion 
that  it  is  neither  necessary  nor  advisable  to  invade  the  uterine  cavity  in  every 
mild  case  of  endometritis;  such  cases  are  best  treated  by  rest  in  bed,  the  applica- 
tion of  an  ice-bag  over  the  uterus,  the  administration  of  ergot  and  vaginal 
irrigations,  the  last  only  when  the  lochia  are  foul.  The  local  application  of 
cold  tends  to  promote  uterine  contraction  and  perhaps  helps  to  inhibit  the 
growth  of  bacteria,  while  the  administration  of  ergot,  as  elsewhere  noted,  aids 
in  promoting  contraction  and  in  furthering  the  processes  of  involution  by 
closing  the  lymphatics  of  the  uterine  wall.  Vaginal  irrigation,  if  carefully 
given  (Part  X),  is  harmless  and  probably  beneficial.  A  2  or  3  per  cent,  solution 
of  carbolic  acid,  or  0.5  or  i  per  cent,  solution  of  lysol,  or  a  25  to  50  per  cent, 
solution  of  hydrogen  peroxide  may  be  injected  every  four  to  six  hours.  When, 
however,  the  symptoms  are  of  a  more  severe  type,  especially  if  they  begin 
to  appear  soon  after  labor,  in  all  cases  in  which  placental  retention  exists  or 
is  strongly  suspected,  the  interior  of  the  uterus  should  be  digitally  examined 
(Part  X).  If  placental  or  other  debris,  such  as  clots  or  pieces  of  membrane, 
is  found,  it  should  be  digitally  removed  and  the  uterus  irrigated  (Part  X). 
The  digital  examination  of  the  puerperal  uterus,  the  removal  of  the  placenta, 
and  the  method  of  giving  the  intrauterine  douche  are  described  in  connection 
with  obstetric  operations  (Part  X).  The  mere  retention  of  membranes  in  the 
absence  of  symptoms  of  infection  is  not  a  justification  for  invading  the  uterine 
cavity  after  delivery,  nor  should  any  violence  be  done  to  the  uterine  wall  in 
the  effort  to  remove  them,  even  if  symptoms  are  present.  In  either  case  the 
remedy  is  more  dangerous  than  the  condition.  On  the  other  hand,  if  the  interior 
of  the  uterus  is  smooth  it  may  be  irrigated,  but  further  manual  or  instrumental 
interference  can  do  nothing  but  harm.  It  is  possible  that  these  injections  act 
simply  by  emptying  the  uterus  of  septic  contents,  and  that  sterile  water  would 
serve  as  well  as  disinfectant  solutions.  Of  the  latter,  perhaps  a  50  per  cent, 
solution  of  alcohol  is  well  worth  trial,  as  much  as  one  and  a  half  to  two  quarts 
being  used.  If  no  benefit  is  observed,  the  injection  may  be  repeated  in  twelve 
hours;  but  if  improvement  does  not  follow  the  second  injection,  little  benefit 
is  likely  to  be  derived  from  further  intrauterine  treatment.  Should  the  in- 
jections appear  to  cause  improvement,  the}'-  may  be  cautiously  repeated  from 
time  to  time,  according  to  results.  Should  no  benefit  be  observed,  it  is  unwise 
to  continue  them,  as  they  are  by  no  means  free  from  danger.  A  careful  bimanual 
examination  should  be  made  in  each  case,  and  in  those  cases  in. which  the  para- 
metrium is  involved,  intrauterine  injections  should  not  be  given,  but  vaginal 
4S 


754  PATHOLOGICAL  PUERPERIUM. 

injections  may  be  employed.  Antiseptics  may  be  introduced  into  the  uterine 
cavity  in  the  form  of  suppositories  or  on  gauze.  The  use  of  the  iodoform  pencil 
is  strongly  advised  by  some,  while  others  advocate  the  use  of  iodoform  gauze. 
I  have  abandoned  the  use  of  both.  Carossa  fills  the  uterus  with  gauze  which 
he  saturates  at  hourly  intervals  with  25  to  50  per  cent,  alcohol.  Among  other 
substances  which  may  be  introduced  by  the  tampon  are  chlorine  water,  tincture 
of  iodine,  and  especially  the  colloidal  silver  of  Cred^  (see  page  751).  In  the 
past  the  curette  has  played  an  important  part  in  the  treatment  of  puerperal 
endometritis,  but  the  best  authorities  have  now  reached  the  conclusion  that 
its  use,  while  often  productive  of  the  greatest  good  in  the  treatment  of  sepsis 
following  abortion,  does  far  more  harm  than  good  in  the  treatment  of  sepsis 
at  full  term.  The  objections  to  its  use  may  be  stated  as  follows:  (i)  It  is 
difficult  to  go  thoroughly  over  the  whole  surface  of  the  uterus;  (2)  the  puerperal 
septic  uterus  is  soft  and  easily  perforated;  this  accident  has  happened  to  expe- 
rienced operators;  (3)  whatever  is  necessary  can  usually  be  done  more  intelli- 
gently and  thoroughly  by  the  finger;  (4)  last  and  most  important,  curetting 
destroys  the  barrier  which  nature  has  established  against  the  progress  of  infec- 
tion, and  which  has  been  discussed  in  connection  with  the  pathology  of  puerperal 
septic  endometritis  (page  719,  Fig.  940).  Moreover,  experience  has  shown  that 
good  results  have  been  obtained  by  methods  similar  to  those  which  I  have 
described.  Kronig  obtained,  by  expectant  and  supporting  measures,  a  mor- 
tality of  4  per  cent.,  and  in  all  his  cases  the  presence  of  the  streptococcus  was 
demonstrated  in  the  lochia.  It  is  doubtless  true  that  in  certain  cases  of 
fever  following  delivery  there  is  prompt  subsidence  of  symptoms  after  curet- 
tage. Such  cases,  however,  are  cases  of  sapremia  which  almost  always  termi- 
nate favorably,  either  spontaneously  or  under  treatment.  If  streptococci  as 
well  as  saprophytes  happen  to  be  present,  curettage  may  result  in  the  exten- 
sion of  the  infectious  process  and  in  serious  and  even  fatal  accidents. 

Resume. — To  sum  up  the  treatment  of  puerperal  endometritis:  (i)  retained 
placenta  should,  when  possible,  be  removed  digitally;  (2)  mild  cases  should  be 
treated  expectantly  by  the  use  of  the  ice-bag,  ergot,  etc.,  vaginal  douches  being 
used  if  the  lochia  are  offensive;  (3)  in  severe  cases  the  uterine  interior  should 
be  carefully  examined  digitally,  and  when  practicable,  bacteriologically ;  debris 
should  be  manually  or  instrumentally  removed;  the  uterus  carefully  irrigated 
and  the  irrigation  repeated  if  necessary  within  twelve  hours,  preferably  with  a 
50  per  cent,  solution  of  alcohol.  This  treatment  to  be  commenced  as  early 
as  possible.  If  intrauterine  treatment  is  not  beneficial,  it  should  be  discontinued 
and  every  precaution  taken  to  prevent  injury  to  the  soft  parts  of  the  mother 
during  manipulations. 

(5)  Mastitis. — (See  page  765.) 

(6)  Pyogenic  Urethritis,  Cystitis,  Pyelitis. — If  infection  has  already  occurred, 
as  shown  by  the  onset  of  cystitis,  the  bladder  should  be  washed  out  every  four 
hours  with  a  weak  solution  of  boric  acid.  This  is  best  done  by  means  of  a  silver 
return  catheter  and  fountain  syringe,  the  bladder  having  been  emptied.  The 
reservoir  should  have  but  a  slight  elevation  above  the  bladder.  No  air  should 
be  admitted.  As  soon  as  the  patient  feels  the  sense  of  fulness  in  her  bladder, 
she  should  be  allowed  to  empty  it.  Urotropin  should  be  given  inwardly.  If 
the  upper  part  of  the  urinary  tract  becomes  infected,  the  resulting  case  is  one 
for  operative  surgery.  Puerperal  gonorrheic  urethritis  is  mentioned  elsewhere. 
(Fig.  950) 

(7)  Puerperal  Salpingitis. — The  treatment  is  that  for  localized  suppuration 
elsewhere.     If  the  diagnosis  is  made  early  an  ice-bag  may  be  applied.     After 


TREATMENT"  OF  PUERPERAL  INFECTION.  755 

pus  has  collected  it  must  be  evacuated,  it  being  understood  that  the  primary 
focus  in  the  uterus  has  been  properly  treated.  The  conservative  vaginal  inci- 
sion should  be  employed  to  reach  the  pus.  Gonorrheal  puerperal  salpingitis 
will  be  mentioned  elsewhere;  likewise  salpingitis  secondary  to  septic  peritonitis. 

(8)  Metritis. — We  must  reiterate  that  puerperal  metritis  is  not  a  clinical 
entity.  The  moment  the  leucocyte  barrier  is  overcome,  or  the  thrombi  in  the 
uterine  sinuses  are  attacked,  the  infection  is  already  to  be  considered  as  having 
extended  beyond  the  uterus.  This  is  best  shown  clinically  by  the  fact  that  no 
indications  for  hysterectomy  for  puerperal  sepsis  can  be  laid  down  save  in  ex- 
ceptional cases  like  an  adherent  placenta,  an  infected  myoma,  etc.,  in  which  the 
operation  is  really  prophylactic. 

(9)  Parametritis. — The  .management  of  a  parametritis,  whether  essential  or 
a  complication,  is  that  of  an  impending  or  actual  abscess-formation  in  general. 
At  the  outset  an  ice-bag  is  applied  and  opiates  given,  both  rendering  especial 
service  in  warding  off  suppuration  and  peritonitis.  The  patient  must  also  be 
kept  immobilized  to  the  greatest  possible  extent.  This  management,  when  put 
in  force  at  an  early  period,  justifies  a  good  prognosis.  If  suppuration  is  under 
way  warm  compresses  about  the  abdomen  may  hasten  it.  Pus  should  be 
evacuated  by  the  posterior  vaginal  incision.  In  order  to  hasten  resolution,  both 
in  abortive  cases  and  after  suppuration,  the  patient  should  be  placed  on  her 
back  with  elevated  hips,  and  the  posterior  cul-de-sac  irrigated  twice  daily  with 
several  quarts  of  hot  water. 

Oophoritis  may  be  regarded  practically  as  a  parametritis ;  it  is  caused  usually 
by  lymphatic  extension  from  the  endometrium. 

(10)  Perimetritis. — Perimetritis  and  parametritis  require  precisely  the  same 
management,  viz.,  absolute  rest,  the  ice-bag,  and  opiates;  so  that  a  differential 
diagnosis  during  the  early  days  is  not  a  matter  of  supreme  importance.  Rest 
must  be  so  absolute  that  no  attempts  at  irrigating  the  birth  tract  are  permissible, 
even  if  the  lochia  are  foul  and  purulent.  The  surgical  treatment  is  along  the 
lines  of  parametritis  and  will  be  discussed  more  fully  in  the  general  section. 

(11)  General  Peritonitis. — In  the  absence  of  general  sepsis,  there  is  an  oppor- 
tunity of  accomplishing  something  by  treatment  directed  to  the  peritoneum.  In 
the  very  earliest  stages  an  attempt  should  be  made  to  limit  the  process  by  ice  and 
opiates.  After  meteorism  has  fully  developed  it  is  of  course  useless  to  expect  any- 
thing from  abortive  treatment.  In  theory,  prompt  laparotomy  with  evacuation  of 
all  the  contents  of  the  peritoneal  cavity — bacteria,  exudate,  etc. — is  indicated ;  but 
only  in  a  very  few  cases  is  this  heroic  resource  efificacious.  The  most  promising 
cases  are  those  in  which  a  sudden  escape  of  pus,  etc.,  has  inoculated  the  entire 
peritoneum,  such  as  occurs  in  rupture  of  an  abscess.  The  surgical  treatment  of 
general  peritonitis  will  be  discussed  more  fully  later  (page  756).  In  the  absence 
of  surgical  intervention,  palliative  treatment  may  give  some  relief.  The  inflated 
abdomen  may  be  subjected  to  warm  packs;  tympanites  may  be  relieved  by 
means  of  a  long  colonic  tube.  Stimulants  of  all  kinds  and  appropriate  nutriment 
are  indicated.  Fortunately,  ^.s  already  stated,  the  end  of  these  patients  is  often 
peaceful. 

(12)  Metrophlebitis  or  Septicaemia  Venosa. — There  is  practically  but  a  single 
indication  in  this  affection — the  prevention  of  metastasis.  This  is  best  fulfilled 
by  absolute  rest  in  bed.  The  least  effort,  as  in  having  the  bedding  changed,  may 
bring  on  a  chill.  It  may  happen  at  times  that  the  loosening  of  the  thrombi  as 
a  result  of  their  suppuration  is  attended  by  hemorrhage  (secondary  post-partum 
hemorrhage).  The  uterus  and  vagina  in  these  cases  must  be  tamponed,  and 
ergot  should  be  given  in  large  doses.     If  the  tampons  do  not  arrest  the  hemor- 


756  PATHOLOGICAL  PUERPERIUM. 

rhage,  intrauterine  injections  of  hot  acetic-acid,  solution,  2  to  6  per  cent.,  may 
be  used  with  vaporization  as  a  last  resort. 

(13)  Phlegmasia  Alba  Dolens. — The  patient  should  be  kept  perfectly  quiet  in 
bed  and  all  manipulations  should  be  avoided  in  order  to  prevent  embolism.  The 
leg  should  be  elevated  and  wrapped  in  cotton.  A  nutritious  diet  is  indicated,  but 
over-stimulation  should  be  avoided  on  account  of  the  danger  of  embolism.  The 
patient  should  remain  in  bed  for  two  weeks  after  the  subsidence  of  the  swelling. 
The  resulting  oedema  is  best  treated  by  the  application  of  a  bandage.  In  the 
cellulitic  form  abscesses  are  likely  to  develop  in  the  femoral  region,  and  should 
be  opened  as  soon  as  practicable  in  order  to  avoid  the  fistulae  which  are  apt 
to  occur. 

Many  local  remedies  are  advised  for  this  condition.  Am^ong  them  are:  paint- 
ing along  the  course  of  the  swollen  veins,  once  daily  or  upon  alternate  days, 
with  tincture  of  iodine;  wrapping  the  limb  in  2  per  cent,  carbolic  acid  solution 
or  a  solution  of  hamamelis;  the  local  application  of  the  ointments  of  belladonna 
and  mercury  either  alone  or  in  combination;  and  the  use  of  various  strengths 
of  ichthyol  in  aqueous  solution.  Of  these,  I  have  found  a  25  to  50  per  cent, 
ichthyol  solution  to  give  the  best  results.  In  some  cases  I  have  used  it  even' 
undiluted. 

3.  SURGICAL  TREATMENT. 

(i)  Curettage. — This  resource,  used  by  many  in  a  routine  fashion,  is  regarded 
by  others  as  a  dangerous  practice.  We  sometimes  see  the  temperature  rise 
and  the  disease  take  a  fatal  turn  after  this  operation.  During  an  interval 
of  ten  years  Bumm  *  has  seen  in  his  own  practice  ten  untoward  results  of  curet- 
tage: 5  cases  of  phlegmasia  alba  dolens,  3  of  fatal  pyemia,  and  2  of  fatal  peri- 
tonitis. The  endometrium  should  never  be  curetted  in  streptococcic  infection; 
in  the  first  place,  80  per  cent,  of  these  patients  recover  spontaneously  from  the 
formation  of  a  protective  layer  of  leucocytes  in  the  decidual  lining  of  the  uterus. 
The  germs  leave  the  uterus  in  connection  with  the  necrosis  and  expulsion  of 
the  decidua;  the  use  of  the  curette  is  therefore  distinctly  meddlesome.  It 
breaks  down  the  defensive  wall  and  allows  the  streptococci  to  penetrate  into 
the  uterus  and  gain  the  peritoneum;  this  being  the  method  by  which  curettage 
may  set  up  peritonitis.  Less  virulent  streptococci  may  attack  the  exposed 
placental  site  and  enter  the  venous  sinuses,  there  causing  purulent  disintegration 
of  thrombi  or  perhaps  an  endophlebitis  of  the  crural  vein  with  resulting  phleg- 
masia alba  dolens.  Curettage,  in  fact,  is  indicated  only  in  putrefaction  of 
decidual  and  placental  remains  with  resulting  sapremia.  Here  the  results  are 
very  satisfactory  because  these  saprophytes  can  exist  only  on  dead  tissue. 
Even  here,  however,  the  fingers  should  be  used  to  remove  all  large  masses 
and  the  placental  site  should  never  be  curetted. 

(2)  Vaginal  Incision  and  Drainage.  (Figs.  962  and  963.) — Incision  through 
Douglas's  pouch  in  acute  pelvic  suppuration  of  puerperal  origin  necessarily  pre- 
supposes an  accurate  diagnosis  which  can  be  made  only  by  bimanual  examination 
under  narcosis.  Kronig  warns  against  the  employment  of  this  resource  lest  a 
recent  adhesion  be  ruptured  with  subsequent  development  of  diffuse  peritonitis. 
As  there  is  no  certainty  that  vaginal  incision  will  lead  to  evacuation  of  the  pus,  the 
operator,  according  to  Kronig,  would  best  pursue  the  expectant  plan.  Quite 
recently  certain  operators  have  advocated  vaginal  incision  and  drainage  in  acute 
pelvic  peritonitis  and  cellulitis. f  A  parallel  instituted  between  this  procedure 
and  the  expectant  management  apparently  shows  the  superiority  of  the  former. 

*  "Ueber  die  chirurgische  Behandlung  des  Kindbettfiebers,"   Halle,    1902. 
t  "American  Journal  of  Obstetrics,"   Mar.,    1902. 


TREATMENT  OF  PUERPERAL  INFECTION. 


757 


The  majority  of  authors  do  not  even  mention  early  vaginal  incision  in  this 
connection.  The  ultimate  removal  of  pus  by  incision  through  the  Douglas 
pouch,  after  due  waiting  for  resorption  to  occur,  is  permissible  if  the  pus  is 
walled  off  and  the  patient  in  good  condition. 

(3)  Extirpation  of  the  Infected  Uterus  and  Laparotomy. — This  is  indicated 
in  cases  which  do  not  improve  after  evacuation  of  the  uterus,  providing  the 
disease  is  still  confined  to  the  latter.  Schultze  performed  this  operation  success- 
fully for  retained  placenta,  Stahl  for  suppuration  of  a  myoma  in  the  puer- 
perium,  Sippel  in  putrid  endometritis,  Prochownik  in  septic  abortion,  etc. 
Many  of  these  hysterectomies  have  been  performed  in  America.  Bumm  *  has 
performed  five  extirpations  of  the  uterus  with  two  recoveries.  The  fatal  cases 
were  all  examples  of  streptococcic  infection.  The  indications  for  this  operation 
are  difficult  to  determine.  If  one  waits  for  the  infection  to  reach  the  confines 
of  the  uterus,   as  shown  by  local  symptoms  in  the  immediate  neighborhood 


Fig  Q62. — Vaginal  Incision 
AND  Drainage.  Shows  the 
incision  being  made  through 
the  posterior  utero-vaginal 
junction  into  Douglas'  cul- 
de-sac. 


/ 


i;.^x^^<^ 


Fig.  963. — Vaginal  Incisiox  and  Drainage.  Gauze 
and  rubber  drainage-tube  introduced  through  the 
vaginal  incision. 


of  the  latter,  operation  as  a  rule  will  result  in  stump  infection  and  subsequent 
peritonitis.  On  the  other  hand,  there  is  a  natural  hesitancy  in  regard  to  per- 
forming hysterectomy  in  incipient  cases,  because  spontaneous  recovery  is 
likely  to  follow  any  type  of  infection.  The  infectious  germs  may  be  propagated  in 
all  directions — into  the  tubes,  veins  and  lymphatics,  and  upon  the  peritoneum. 
Cases  of  this  type  are  inoperable.  Something  can  be  done  toward  the  diagnosis 
of  operability  by  anesthetizing  the  patient  and  a  thorough  bimanual  palpation  of 
the  tubes,  ovaries,  and  pelvic  connective  tissue.  To  perform  laparotomy 
as  a  last  resort,  in  default  of  precise  indications,  is  not  justifiable,  although 
now  and  then  a  cure  may  be  accomplished.  If  a  puerperal  pyosalpinx  develops, 
the  germ  is  usually  the  streptococcus  which  maintains  its  virulence  un- 
changed. The  danger  of  infecting  the  peritoneal  cavity  in  attempting  to 
remove  a  pyosalpinx  is  very  great.  Miliary  abscesses  and  detached  colonies 
,  *  Vide  supra. 


758  PATHOLOGICAL  PUERPERIUM. 

of  germs  may  be  present  in  the  inflammatory  zone  which  surrounds  the  tumor. 
Premature  intervention  in  pyosalpinx  is  strictly  contraindicated,  for  it  may 
be  that  the  septic  process  is  about  to  become  localized.  In  regard  to  septic 
peritonitis,  all  our  resources — simple  incisions,  irrigation,  and  drainage — notably 
fail  when  a  large  amount  of  peritoneal  surface  is  involved.  Bumm  *  cites  a 
case  in  which  he  made  a  free  incision  in  the  linea  alba,  took  out  a  portion  of 
the  intestine,  removed  all  exudate,  irrigated  the  abdominal  cavity  with  many 
quarts  of  saline  solution,  tamponed  the  pelvic  cavity  with  iodoform  gauze, 
and  finally  made  counteropenings  to  secure  abundant  drainage.  These  patients 
usually  perish  rapidly  from  collapse;  enormous  numbers  of  streptococci  are  found 
post  mortem  upon  the  peritoneum  of  all  the  abdominal  organs.  To  combat 
peritonitis  successfully,  laparotomy  would  have  to  be  performed  as  soon  as 
the  disease  begins,  with  removal  of  the  infected  uterus  at  the  same  time.  This 
intervention  is  too  severe  for  most  patients  to  undergo.  The  only  recoveries 
common  in  puerperal  peritonitis  occur  in  cases  of  encapsulated  collections  of 
pus.  Pelvic  abscess  is  in  itself  a  favorable  termination  for  puerperal  sepsis, 
because  it  indicates  arrest  of  the  infective  process.  There  is  little  danger  that 
the  pus  will  burrow,  and  incision  is  indicated  only  when  the  original  small 
purulent  foci  have  coalesced  to  form  a  large  abscess.  Puncture  is  more  practi- 
cable than  incision  in  these  cases.  If  the  abscess  is  opened  at  the  abdominal 
wall,  a  count  crop  ening  should  be  made  in  the  vagina,  and  vice  versa. 

(4)  Excision  of  Veins. — The  question  of  the  excision  of  veins  as  preventive 
of  pyemia  naturally  arises.  Autopsies  frequently  show  veins  plugged  with 
purulent  thrombi  which  were  amenable  to  excision,  the  lesion  being  limited 
to  a  small  portion  of  a  single  vein ;  for  example,  one  of  the  spermatics.  Physical 
exploration  under  deep  narcosis  will  sometimes  enable  the  operator  to  feel 
the  infundibular  ligament  of  the  pelvis  as  a  thick,  indurated  cord.  The  technique 
required  for  the  excision  of  these  veins  is  not  difficult.  Bumm  has  operated 
three  times,  but  unfortunately  without  success.  In  one  case  a  septic  phlegmon 
was  found  in  association  with  the  thrombo-phlebitis ;  in  a  second,  which  prom- 
ised well,  the  left  spermatic  vein  was  the  seat  of  suppuration.  It  was  resected 
within  wide  limits  and  the  pyemic  chills  ceased  within  three  days.  The  patient 
succumbed,  however,  from  a  fresh  purulent  focus  in  the  same  vein.  In  the 
third  case,  as  in  the  first,  the  phlebitis  was  accompanied  by  an  extravascular 
phlegmon.  Trendelenburg  succeeded  in  saving  a  patient  by  this  operation  in 
1902.*     This  form  of  intervention  appears  to  be  justifiable  as  a  last  resort. 

(5)  Atmocausis. — Sneguireff's  method  of  vaporization  has  been  suggested 
by  Diihrssen  t  for  septic  or  putrid  endometritis.  As  this  form  of  intervention 
must  necessarily  produce  obliteration  of  the  uterine  cavity  with  consecutive 
atrophy  of  the  organ,  it  could  be  employed  only  in  women  near  the  climacteric, 
and  even  then  solely  as  a  last  resort.  The  technique  is  very  simple.  A  boiler 
heated  by  alcohol  has  a  metallic  supply  tube  attached  which  is  introduced 
into  the  uterine  cavity  through  a  fenestrated  catheter  which  is  surrounded  in 
turn  by  another  tube  of  non-conducting  material  for  the  protection  of  the 
cervix.  The  contact  of  the  steam  with  the  uterine  cavity  should  not  exceed 
one  and  a  half  to  two  minutes.  The  pain  is  insignificant,  so  that  no  anesthetic 
is  required.     I  have  had  no  experience  with  this  method. 

*  Vide  supra. 


ANOMALIES  OF    THE   BREASTS. 


r59 


VI 


ANOMALIES  OF  THE  BREASTS. 


1.  Absence  of  Mammae,  or  Amazia. — This  anomaly  is  extremely  rare.  It 
has  been  said  that  absence  of  one  breast  occurs  only  in  women,  and  absence 
of  both  only  in  monsters  who  are  otherwise  extremely  deformed.  A  stunted 
condition  of  the  breasts  is  often  associated  with  imperfect  development  of  the 
true  sexual  organs. 

2.  Hypertrophy. — This  anomaly  is  also  rare,  and  generally  occurs  in  those  quite 
young.  One  breast  is  often  larger  than  the  other.  Lactation  sometimes  dimin- 
ishes the  size  of  the  hypertrophied  breasts. 

3.  Lactation  Atrophy  of  the  Breast. — A  phenomenon  well  known  to  the  laity, 
but  seldom  or  never  alluded  to  in  textbooks  on  obstetrics,  is  frequent  dwindling 
away  of  the  mammary  fat  after  lactation.  That  the  gland  itself  is  not  involved 
is  shown  by  the  restoration  of  the  original  bust  after  a  new  conception,  subject, 
of  course,  to  the  changes  incidental  to  multiparity.  The  cause  of  this  atrophy 
appears  to  have  nothing  specific  in  its  character,  but  it  is  one  of  the  greatest 
sources  of    anxiety  to   modem 

woman,  as  shown  by  the  num- 
ber of  expedients  in  vogue  to 
overcome  or  conceal  it.  Theo- 
retically, it  is  possible  to  pro- 
duce mammary  hypertrophy  by 
massage  and  inunctions  of  fats. 
Clinically,  the  results  are  most 
disappointing. 

The  same  is  true  of  the  use 
of  goat's  rue  and  other  drugs.  A 
relatively  small  amount  of  par- 
affin injected  into  the  breast  will 
produce  the  desired  effect;  I 
have  had  no  personal  experience 
in  the  matter,  but  know  of  acci- 
dents from  its  use. 

4.  Supernumerary    Breasts : 

Polymazia  or  Polymastia. — This  condition  is  rare.  These  extra  mammee  are  gen- 
erally found  on  the  chest  below  the  normal  gland  and  more  median  in  situation. 
However,  instances  are  on  record  of  their  being  found  in  the  most  varied  situa- 
tions. This  fact  does  not  admit  the  theory  of  reversion.  Men  seem  to  exhibit 
this  phenomenon  as  frequently  as  women,  if  not  more  so.  Heredity  seems  to 
account  for  it  in  some  instances.  Supernumerary  breasts  vary  in  size  from  a 
minute  collection  of  glandular  tissue  to  a  full-sized  breast  secreting  the  normal 
amount  of  milk  (Fig.  336). 

5.  Anatomical  Anomalies  of  the  Nipples  (Fig.  964). — (i)  Congenital  absence 
(athelia) :  This  condition  rarely  occurs.  When  acquired,  it  is  generally  due  to 
injury,  or  it  may  result  from  suppuration  of  the  infantile  breast.  (2)  Flat  and 
inverted  nipples  (microthelia) :  This  anomaly  may  be  either  congenital  or  acquired 
and  is  common  as  the  result  of  corset  pressure.  It  should  be  recognized  at  the 
examination  of  pregnancy  (Fig.  964).  The  treatment  consists  in  drawing 
out  the  nipple  with  the  fingers  or  breast-pump  in  the  latter  part  of  gestation. 
Breast-shields  may  obviate  the  difficulty  of  nursing.  Artificial  feeding  may 
become  necessary.     (3)  Fissured  nipples  (Fig.  971):  The  nipples  are  exposed  to 


Fig.   964. — Comparison    of  Faulty  and  Normal 
Development  of  the  Nipples. 


760 


PATHOLOGICAL   PUERPERIUM. 


the  discomfort  of  chafing  from  the  continual  changes  of  dryness  and  moist- 
ure to  which  they  are  subjected.  Many  parturient  women  suffer  from  this 
trouble.  There  is  danger  of  the  entrance  of  micro-organisms  and  of  subsequent 
inflammation.  Treatment  is  chiefly  prophylactic,  as  elsewhere  described  (page 
187).  ■  Exposure  of  the  nipples  to  the  ordinary  atmosphere  is  excellent  to 
harden  them.  Boric-acid  solution  as  a  wash  is  most  useful.  After  ulceration 
has  once  been  established  vigorous  measures  are  necessary. 


IX.  ANOMALIES  OF  THE  MILK  SECRETION. 

I.  Deficient  Secretion :    Oligolactia  or  Agalactia. — A  deficiency  of  milk   in 
the    nursing    woman   is    quite   common,    but   a    complete   suppression   is    not 
frequent.     Deficiency  may  be  caused  by  a   congenital   or    acquired  defect  in 
the  structure  of  the  mammary  glands.     Ill  health,  advanced  age,  or  obesity 
may  also  be  a  cause.     It  sometimes  occurs  after  a  pre- 
mature or  still-birth,  and  also  follows  a  previously  abund- 
ant supply  of  milk,  and  is  then  often  due  to  continuous 
overexertion.     The  milk  secretion  is  mainly  dependent 
upon  the  general  condition  of  the  mother  and  upon  the 
diet.      Treatment:  If  the  cause  is  some  defect  in  the  struc- 


FiG    965. — Ordinary 
Breast-pump. 


Fig.  966. — Nipple  Shield. 


ture  of  the  breasts,  treatment  is  of  little  avail.  If,  however,  there  are  other  causes, 
such  as  ill  health,  overwork,  etc.,  a  carefully  regulated  diet,  change  of  air  and 
scene,  tonics,  and  other  hygienic  measures  are  often  effective.  Gentle  massage 
has  been  followed  by  beneficial  results.  Crabs,  whether  hard-  or  soft-shelled, 
have  been  found  the  best  milk  producers  among  foods.  Many  kinds  of  sea  food, 
especially  shell-fish,  seem  to  have  the  same  influence.  Boiled  fresh  beets,  with- 
out vinegar,  are  one  of  the  best  vegetables. 

2.  Excessive  Secretion. — (i)  Polygalactia:  This  condition  is  one  of  an  excessive 
amount  of  milk.  Congestion  and  engorgement  of  the  breast  are  not  necessarily 
present.  Its  occurrence  is  not  frequent.  It  may  develop  during  the  first  part 
of  lactation  and  gradually  subside.  If  it  continues,  to  the  great  discomfort 
of  the  mother,  means  should  be  taken  to  overcome  it.  Treatment  consists  in 
regular  times  of  nursing,  in  emptying  the  breasts  by  massage,  the  breast- 
pump,  or  compression.  The  diet  may  be  restricted  and  the  amount  of  fluids 
diminished.     Laxatives    should  be  given.     (2)  Hyper  lactation:    Lactation  pro- 


DISEASES  OF   THE  BREAST.  761 

longed  beyond  the  ninth  month  may  result  in  an  exhausted  physical  condition 
of  the  mother,  which  is  sometimes  termed  tabes  lactealis.  This  habit  is  most 
prevalent  in  the  lower  walks  of  life.  The  mother  may  develop  symptoms  of 
anemia  accompanied  by  neuralgic  pains.  Nervous  manifestations  often  follow. 
The  symptoms  are  profound  anemia  and  pains  in  the  upper  extremities  during 
nursing.  Phthisis  also  may  develop.  The  child  must  be  weaned  at  once.  Tonics 
must  be  administered  to  the  mother,  while  a  change  of  air  will  be  found  very 
beneficial.  (3)  Galactorrhea:  This  affection  consists  in  a  continuance  of  the 
milk  secretion  with  constant  flow  between  the  periods  of  nursing.  The  milk 
is  of  poor  quality.  Both  breasts  are  generally  affected.  In  certain  cases  the 
quantity  of  milk  is  excessive,  resulting  in  exhaustion  of  the  mother.  The 
causes  are  unknown.  It  may  be  a  nervous  affection.  The  almost  continuous 
flow  of  milk  with  loss  of  strength  and  interference  with  nutrition  brings  about 
anemia,  emaciation,  and  nervous  disorders.  The  treatment  is  unsatisfactory. 
Iodide  of  potassium  and  ergotin  are  recommended;  atropin  locally  (i  gr.  to  i  oz. 
of  glycerin)  I  have  found  of  great  value.  Return  of  menstruation  sometimes 
increases  the  flow.  Belladonna  ointment  is  preferred  by  some;  I  have  found 
it  less  certain  than  atropin  in  glycerin  or  vasogen.  A  lotion  for  bathing  the 
nipples,  consisting  of  a  5  per  cent,  solution  of  cocaine  hydrochlorate  in  equal 
parts  of  glycerin  and  water,  often  assists  in  the  treatment.  Saline  laxatives  to 
keep  the  bowels  open  are  of  benefit.  Electricity  is  not  always  attended  by  the 
results  hoped  for. 

3.  Quailitative  Anomalies. — The  quality  of  the  milk  is  also  variable,  depending 
upon  many  conditions.  The  diet  of  the  mother  is  a  very  potential  factor  in  in- 
fluencing the  quality  of  the  milk.  This  should,  as  a  rule,  be  about  the  same  as 
she  has  always  been  accustomed  to;  it  should  comprise  plain,  mixed  foods 
with  a  slight  excess  of  fluids;  milk  taken  between  meals  is  beneficial;  the  inter- 
vals between  nursing  periods  should  be  carefully  regulated;  excessive  emotion 
of  any  kind  is  always  to  be  avoided. 


X.   DISEASES  OF  THE  BREAST. 

1.  Areolar  Inflammation. — Inflammation  and  even  abscess  of  the  glands  of 
Montgomery  may  occur,  but  may  be  prevented  by  cleanliness  or  treated  by  in- 
cision. 

2.  Congestion  and  Engorgement. — Engorgement  and  congestion  of  the  breasts, 
"  caked  breasts,"  usually  occur  on  the  third  day;  the  pressure  and  irritation  being 
so  great  as  sometimes  to  cause  pyrexia.  The  treatment  consists  in  securing 
profuse  serous  discharges  from  the  intestines  with  saline  cathartics,  in  the  appli- 
cation of  heat  to  the  breasts  in  the  shape  of  hot  stupes  under  pressure,  and  in 
emptying  the  breasts  by  digital  massage  through  hot  stupes  (Figs.  967,  968, 
969).  Saline  catharsis,  moist  heat  with  pressure,  and  rest  are  the  principles 
in  the  treatment  of  caked  breasts. 

3.  Sore  Nipples. — Simple  erythema,  excoriation,  erosion  (Fig.  970),  fissures  or 
cracks,  and  eczema  of  the  nipples  are  all  included  under  the  term  "  sore  nipples," 
and  all  these  conditions  can  usually  be  prevented  by  proper  attention  to  the  nip- 
ples during  pregnancy  and  the  early  puerperium.  The  prophylactic  treatment 
consists  in  the  preparation  of  the  nipples  for  lactation  during  pregnancy.  During 
the  later  months  the  nipples  should  be  washed  daily  with  soap  and  water  and 
carefullv  massaged  with  sterile  vaseline  and  alcohol.     (See  page  187.)     The  cura- 


762 


PATHOLOGICAL  PUERPERIUM. 


tive  treatment  consists  in  careful  cleansing  after  each  nursing  with  boric-acid 
solution;  in  the  use  of  a  nipple  shield  (Fig.  966);  in  the  application  of  bismuth 
and  castor  oil,  compound  tincture  of  benzoin,  oxide  of  zinc,  or  nitrate  of  silver, 

4.  Mastitis ;  Mammary  Lymphangitis;  Galactophoritis. — Varieties:  Three 
varieties  may  usually  be  recognized:  namely — (a)  subcutaneous,  (6)  parenchyma- 
tous, {c)  submammary  (Fig.  971).  Mastitis  was  formerly  of  common  occurrence, 
but  since  its  infectious  nature  has  been  recognized  it  is  much  less  common.  It 
occurs  more  frequently  in  primiparae  and  during  the  second  and  third  weeks  of 
the  puerperium,  but  may  occur  late  in  lactation.  It  is  rare  after  the  fourth  preg- 
nancy. Etiology:  All  forms 
of  mastitis  are  to  be  re- 
garded as  forms  of  infec- 
tion. The  infecting  agent 
is  usually  Staphylococcus 
aureus,  less  often  the  strep- 
tococcus. Staphylococcus 
albus  is  found  in  the  secre- 
tions of  healthy  women  in 
from  80  to  94  per  cent,  of 
cases,  and,  as  a  rule,  is  of 
no  pathological  importance 
to  either  mother  or  child 
(Olshausen  and  Veit).  The 
starting  point  of  infection 
is  usually  a  fissure  or  an 
erosion  of  the  nipple,  but 
the  milk  ducts  may  be- 
come infected  without  this. 
Occasionally  the  process 
starts  from  an  abrasion  of 
the  areola  or  skin  surface  of 
the  breast.  Infection  by 
micro-organisms  circulat- 
ing in  the  blood  has  been 
assigned  as  a  cause,  but 
this  claim  has  not  been 
proved.  Metastatic  ab- 
scesses of  the  breast  may, 
of  course,  occur  in  pyemia 
as  the  result  of  thrombotic 
infection.  Inspissation  of 
milk,  caked  breasts,  was 
formerly  supposed  to  be  the  cause,  but  this  has  been  disproved.  It  is,  in  my 
opinion,  a  predisposing  cause.  The  superficial  varieties  of  mastitis  are  the  result 
of  lymphatic  infection,  while  in  the  more  deeply  seated  it  is  generally  believed 
that  the  infection  is  transmitted  through  the  milk  ducts.  Contact  of  the 
nipple  or  breast,  especially  if  eroded  or  fissured,  with  unclean  hands,  clothes, 
breast-pump,  etc.,  and,  under  certain  conditions,  with  the  child's  mouth,  are  all 
sources  of  infection. 

(a)  Subcutaneous  Mastitis  (Fig.  971). — This  is  a  superficial  and  circum- 
scribed inflammatory  process  usually  located  under  or  near  the  areola.  It  is 
always   due  to  infection  through  the  lymphatics.     The  gland   proper  is  not 


Fig.  967. — Massage  and  Milking  of  Distended  or 
"Caked"  Breasts  through  Hot  Moist  Flannel. 
The  left  hand  supports  the  breast,  while  the  fingers  of 
the  right  hand  produce  gentle  but  firm  massage  radiat- 
ing from  the  base  toward  the  nipple. 


DISEASES  OF   THE  BREAST. 


763 


involved.  The  treatment  includes,  in  the  early  stages,  supporting  measures  and 
the  application  of  a  50  per  cent,  ichthyol  solution,  and,  if  abscess  forms,  incision 
and  evacuation  of  the  pus,  followed  by  an  antiseptic  dressing.  In  this  form  of 
mastitis  it  is  not  always  necessary  to  remove  the  child  from  the  breast.  Care 
should  be  taken  to  make  the  incision  either  entirely  within  or  entirely  without 
the  areola,  since  pigmentation  may  follow  the  line  of  incision.  In  very  rare 
cases  the  inflammation  takes  on  an  erysipelatous  type,  becomes  rapidly  dif- 
fused, and  is  followed  by  extensive  suppuration  and  sloughing.  The  axillary- 
glands  may  be  enlarged  and  tender.  Accompanying  the  local  process  are  grave 
constitutional  symptoms,  such  as  chills,  high  fever,  and  general  prostration. 

Inflammation  of  the 
Glands  of  Montgomery. — 
Suppuration  of  the  glands 
of  Montgomery  within  the 
areola  sometimes  occurs, 
and  after  rupture  obstinate 
ulcers  may  form.  The  glands 
should  be  incised,  the  pus 
evacuated,  and  an  antiseptic 
dressing  applied.  An  ulcer, 
if  present,  should  be  treated 
on  general  surgical  princi- 
ples. 

(6)  Parenchymatous 
Mastitis. — Inflammation  of 
the  gland  proper  is  usually 
called  "parenchymatous 
mastitis."  There  are,  how- 
ever, two  distinct  forms 
which  may  be  clinically  rec- 
ognized :  in  one  the  inflam- 
mation begins  in  the  acini 
(Fig.  971),  and  in  the  other 
it  begins  in  the  interstitial 
tissue  (Fig.  971).  When  it 
begins  in  the  acini,  the  in- 
terstitial tissue  becomes 
secondarily  involved,  and 
vice  versa.  If  the  inflam- 
matory process  begins  in  the 
parenchyma,  the  symptoms 
are  a  chill  or  chilly  sensation 

and  a  sharp  rise  of  temperature,  perhaps  to  104°  F.  or  even  higher.  The 
patient  seldom  complains  of  pain  in  the  breast,  but  examination  discloses  a 
hard,  localized  swelling  which  is  tender  to  the  touch  but  not  unbearably  so; 
there  may  also  be  a  slight  redness  of  the  skin.  When  the  process  begins  in  the 
interstitial  tissue,  it  is  also  accompanied  by  localized  swelling,  which,  how- 
ever, is  not  at  first  well  defined.  This  swelling  gradually  increases  and  redness 
of  the  skin  soon  appears.  In  this  form  of  mastitis  the  temperature  rise  is 
gradual  and  a  well-marked  chill  is  not  common,  although  chilly  sensations 
may  occur.  Whenever  the  fever  continues  for  thirty-six  hours,  it  is  likely 
that  a  suppuration  is  taking  place;  a  rapid  pulse  is  also  considered  suspicious. 


Fig.  968. — Massage  and  Milking  of  Distended  or 
"Caked"  Breasts  through  Hot  Moist  Flannel. 
Both  hands  are  used  to  jointly  massage  the  breast 
and  empty  the  milk  ducts. 


764 


PATHOLOGICAL  PUERPERIUM. 


Fig.  969. — Massage  and  Milking  of  Distended  or  "Caked"  Breasts  through  Hot 
Moist  Flannel.  After  softening  of  the  breasts  by  the  methods  shown  in  Figs.  967 
and  968,  the  fingers  of  one  hand  are  often  sufficient  to  relieve  the  tension  and  empty 
the  milk  ducts  by  massaging  from  the  base  to  the  nipple. 


Fig.  970. — Superficial  Erosion  of  the  Left  Nipple. 


DISEASES  OF   THE   BREAST. 


765 


The  prophylactic  treatment  has  already  been  referred  to  and  applies  to  all 
varieties  of  mastitis.  It  embraces  the  proper  care  of  the  breasts  and  nipples 
and  of  the  child's  mouth,  and  also  the  prompt  treatment  of  erosions  and  fissures. 
Engorgement  of  the  breasts  and  inspissation  of  milk  should  be  treated  by  mas- 
sage through  hot  flannel,  thus  softening  and  relieving  tension  by  milking  into 
the  flannel  (Figs.  967  to  969),  by  bandaging  the  breast  in  such  a  way  as  to 
secure   firm   compression    (Fig.  972);    and    by  the   administration  of   a   saline 


Jhf&rstitial 
Mastitis 


Retromastitis 
J^3ubmammary  Abscess) 


Deep  lobe 


Infected 
lobules 


ErosioTt 


MUkDticts 

Parsnchi/mat^is 
Mastitis 


Pig.  971. — The  Extension  of  Infective  Processes  in  the  Breast.     The  course  and 
site  of  the  infection  are  shown  in  color. 


cathartic.     After  an  inflammatory  process  has  begun,  however,  manipulation 
can  only  do  harm. 

The  curative  treatment  before  suppuration  has  occurred  consists  first  in  re- 
moving the  child  from  the  breasts,  which  should  then  be  supported  but  not 
compressed.  An  ice-bag  should  then  be  applied  over  the  inflamed  area  and  relief 
may  be  afforded  by  compresses  soaked  in  lead-and-opium  wash  and  covered  by 
oiled  silk  or  rubber  tissue.     Free  serous  movements  of  the  bowels  should  be  early 


766 


PATHOLOGICAL  PUERPERIUM. 


secured.  These  measures,  however,  should  not  be  allowed  to  delay  timely  sur- 
gical treatment,  which  should  be  instituted  as  soon  as  the  presence  of  pus  can 
be  determined. 

After  suppuration  has  occurred  in  cases  of  subcutaneous  abscess,  local  anes- 
thesia will  usually  be  sufficient,  as  by  cocain  or  ethyl  chloride.  In  some  cases 
general  anesthesia  will  be  required,  nitrous  oxide  being  most  desirable.  The 
lowest  point  of  the  abscess  should  be  located  as  nearly  as  possible  and  the  incision 
should  be  large  enough  to  admit  the  finger,  and  should  be  in  a  direction  radiating 
from  the  nipple  in  order  to  avoid  severing  one  of  the  lacteal  ducts.  When  prac- 
ticable the  incision  should  be  made  in  the  mammary  fold  so  as  to  avoid  an  un- 
sightly scar  of  the  breast.  The  finger 
should  be  used  to  remove  broken- 
down  tissue  and  to  break  up  any  thin 
partitions  which  may  separate  or  only 
partially  separate  a  neighboring  pus 
cavity.  One  or  more  counter  open- 
ings may  be  made  in  order  to  secure 
free  drainage.  The  cavity  is  then  irri- 
gated with  peroxide  of  hydrogen  or 
some  other  mild  antiseptic  solution, 
the  opening  packed  with  gauze,  and 
an  antiseptic  dressing  with  a  moder- 
ately firm  bandage  is  applied.  In  from 
twenty-four  to  thirty-six  hours  the 
gauze    should  be   removed    and  the 


A 

16  1 

nc^es 

B 

W 
(D 

X 

u 

c 

lO 
(0 

C 

Cloth  folded  rcaiy  for  cutting. 


Fig.  972. — Murphy  Breast-binder  in 
Place. 


Blndpr  completed.    Piece  N03. 1  and  2  together  and  Chen  3  and  4  together  to  fonn  the  ahouldei' 


Fig.  973. — Pattern  of  Murphy  Breast- 
binder  Used  at  the  New  York  Maternity 
Hospital. 


openings  lightly  packed.  As  soon  as  the  discharge  becomes  very  slight  the  gauze 
is  removed  and  the  breast  firmly  compressed.  If  healing  is  not  satisfactory  or  if  the 
cavity  remains  full  of  thick  pus,  better  results  may  perhaps  be  secured  by  the  use 
of  perforated  drainage-tubes,  which  should  not  be  less  than  one-fourth  inch  in 
diameter.  The  dressing  is  changed  the  following  day,  and  after  that  allowed  to 
remain  for  four  days,  when  the  tube  or  tubes  should  be  removed  and  shortened 
one-half.  It  is  desirable  to  remove  the  tubes  within  two  weeks  or  less  if 
possible.  Their  prolonged  retention  is  likely  to  cause  fistulce.  The  aim  of 
either  method  is  to  secure  drainage  while  at  the  same  time  promoting  the  rapid 
closure  of  the  cavity.     As  a  rule,  this  is  better   accomplished  by  gauze  than 


DISEASES  OF   THE   BREAST. 


7G7 


by  drainage-tubes.     If  the  latter  should  be  deemed  best  at  first,  it  is  wise  to 
substitute  a  light  gauze  packing  as  soon  as  circumstances  will  permit. 

(c)  Submammary  Abscess  (Fig.  971). — This  variety  of  abscess  is  situated 
under  the  gland  and  is  the  result  of  the  extension  of  abscess  formation  from  the 
gland  proper.  The  symptoms  include  pain,  which  is  deeply  seated,  oedematous 
swelling  of  the  breast  and  surrounding  skin  with  little  or  no  redness,  inability 
to  move  the  arm  freely,  swelling  of  the  axillary  glands,  and  the  general  symp- 


FiG.  974. — Y-Shaped  Breast-binder  Used  at_the 
Boston  Lying-in  Hospital. 


Fig.  975. — Cross  Bandage  op  one 
Breast. 


Fig.  976. — Cross  Bandage  of  the  Two  Breasts. 


Fig.  977. — Triangle   Bandage   of 
One  Breast. 


toms  of  sepsis — chills,  fever  and  prostration.  The  breast  feels  as  though  it  were 
floating  on  a  fluid  base.  If  the  pus  is  not  evacuated,  it  may  burrow  in  any 
direction,  and  has  even  been  known  to  perforate  the  chest-wall  and  enter  the 
pleural  sac.  I  once-  saw  a  case  in  consultation  in  which  [a  submammary 
abscess  had  passed  unrecognized,  death  resulting  from  sepsis  and  pyemia, 
as  was  proved  by  autopsy.  The  presence  of  pus  is  determined  by  the  aspirating 
needle,  the  breast  being  drawn  upward  and  held  while  the  needle  is  introduced 
along  the  chest-wall  beneath  the  gland.  A  grooved  director  is  then  passed  in 
and  an  opening  made  large  enough  to  admit  the  finger.     The  further  treatment. 


768  PATHOLOGICAL  PUERPERIUM. 

by  irrigation,  drainage,  etc.,  is  the  same  as  that  already  described  for  abscess  of 
the  gland  proper.  Special  care  should  be  taken  to  secure  free  communication 
between  a  submammary  abscess  and  any  abscess  in  the  gland  proper. 

5.  Galactocele. — Galactocele  is  a  milk  tumor  due  to  occlusion  of  one  or  more 
lactiferous  ducts,  and  is  a  rare  condition  and  of  little  importance.  Puncture  of 
the  tumor  may  become  necessary,  but  heat  with  pressure  or  massage  through 
hot  stupes  (Figs.  967,  968,  969)  will  usually  suffice. 


XI.    BLOOD  CONDITIONS. 

1.  Puerperal  Thrombosis  and  Embolism. — The  blood  in  pregnancy  is  pecu- 
liarly coagulable  and  the  circulation  sluggish.  With  these  conditions  only 
mechanical  obstruction  is  necessary  to  cause  the  formation  of  a  clot.  This  takes 
place  in  one  of  the  venous  trunks  and  is  followed  by  serious  consequences.  The 
great  importance  attaching  to  thrombi  is  their  liability  to  break  up  and  form 
emboli.  These  are  carried  along  to  the  smaller  peripheral  vessels.  Puerperal 
thrombosis  is  most  common  after  severe  post-partum  hemorrhage.  Throm- 
bosis of  the  veins  is  the  most  common  cause  of  sudden  death  both  in  labor 
and  in  the  puerperium.  The  femoral,  pelvic,  and  uterine  veins  are  the  most 
frequent  seat  of  this  trouble.  Large  soft  clots  may  be  formed  in  the  event  of 
partial  detachment  of  the  placenta,  or  of  imperfect  contraction  of  the  uterus 
followed  by  sudden  hemorrhage  which  causes  a  weakened  heart  action.  These 
clots  extend  from  the  larger  sinuses  toward  the  heart.  Any  sudden  disturbance 
may  dislodge  bits  of  these  masses  and  the  blood-current  will  drive  them  on  as 
emboli.  The  symptoms  of  puerperal  thrombosis  are  very  sudden.  With  no 
prodromes  there  occur  a  distressing  dyspnea  and  air  hunger.  The  patient 
suffers  the  throes  of  suffocation.  Cyanosis  or  pallor  spreads  over  the  surface 
of  the  body,  which  becomes  cold  and  clammy.  The  heart  is  rapid  and  irregular 
and  the  pulse  small  and  feeble.  The  patient  fears  impending  death.  This  may 
occur  with  a  sudden  convulsion.  However,  recovery  may  gradually  take 
place  from  the  slow  absorption  of  the  clot.  A  rare  occurrence  is  the  formation 
of  clots  in  the  arteries  of  puerperal  women,  instead  of,  or  coincident  with, 
the  formation  of  clots  in  the  veins.  The  symptoms  will  depend  upon  the 
particular  organ  affected.  If  the  cerebral  arteries  are  obstructed,  then  par- 
alysis and  aphasia  result;  if  the  ophthalmic,  blindness  follows.  When  the  clot 
is  in  the  brachial  or  femoral  artery,  the  corresponding  limb  will  grow  cold  with 
loss  of  sensation  and  motion,  or  it  may  be  the  seat  of  neuralgic  pain.  Pulsation 
is  absent  below  the  obstruction  and  increased  above  it.  If  the  collateral  circu- 
lation is  not  sufficient  for  the  needs  of  the  limb,  then  gangrene  may  occur.  The 
diagnosis  is  usually  not  difficult.  The  prognosis  is  grave.  Most  of  these  patients 
die  before  medical  aid  can  be  summoned.  The  cause  of  death  is  disputed,  some 
believing  it  to  be  cerebral  anemia,  others  cardiac  syncope,  but  it  is  probably 
asphyxia.  For  treatment,  full  doses  of  cardiac  and  respiratory  stimulants  should 
be  administered.  To  relieve  pulmonary  congestion  leeches  should  be  applied. 
The  most  absolute  rest  and  quiet  must  be  enjoined.  The  diet  must  be  liquid. 
Oxygen  inhalations  may  be  of  benefit. 

2.  Hematoma. — (See  Maternal  Dystocia,  page  613,  and  Puerperal  Hemor- 
rhages, page  704.) 

3.  Puerpieral  Anemia. — A  tendency  to  anemia  probably  exists  during  preg- 
nancy. After  the  child  is  bom  there  is  a  return  to  the  normal  condition  of  the 
blood  before  the  completion  of  involution  of  the  uterus.     When  this  change 


DISEASES  OF   THE   NERVOUS  SYSTEM.  769 

does  not  occur,  the  woman  becomes  markedly  anemic.  The  etiology  is  not 
clear.  It  may  be  due  to  a  serious  constitutional  disorder.  The  patient 
may  be  possessed  of  slight  powers  of  recuperation.  Acute  anemia  caused 
by  hemorrhage  may  be  the  forerunner.  The  symptoms  are  great  weakness 
and  pallor,  neuralgic  pains  and  backache.  There  is  poor  appetite.  Hemor- 
rhages are  readily  caused,  and,  as  a  rule,  are  from  the  mucosa.  The  diagnosis  is 
made  from  the  symptoms,  physical  signs,  and  blood  examination.  The  prog- 
nosis is  uncertain.  The  disease  yields  generally  to  prompt  treatment,  but  if 
neglected  it  may  develop  into  pernicious  anemia.  For  treatment,  strict  hygienic 
measures  must  be  enforced  and  the  diet  should  be  nutritious  and  carefully  regu- 
lated. Rest  and  fresh  air  are  most  beneficial.  The  child  may  have  to  be 
weaned.  Change  of  air  and  scene  and  mental  diversion  are  very  useful. 
Tonics,  especially  iron  and  arsenic,  are  indicated. 


XII.    DISEASES  OF  THE  NERVOUS  SYSTEM. 

1.  Lesions  of  the  Sacral  Plexus. — In  a  generally  contracted  pelvis,  or  in  one 
with  a  flattened  promontory,  or  in  septic  pelvic  inflammations  or  exudates, 
pressure  upon  the  sacral  plexus  may  result  during  labor  or  the  puerperium. 
Neuralgia,  hyperesthesia,  paralysis,  anesthesia,  and  atrophy  may  occur.  The 
sacral  and  sciatic  nerves  are  extremely  sensitive  to  pressure,  and  movement  of 
the  leg  on  the  affected  side  causes  extreme  pain  both  in  the  pelvis  and  down  the 
leg.  The  prognosis  is  favorable,  and  the  treatment  consists  in  the  cure  of  the 
septic  condition  if  this  is  the  cause,  and  in  the  general  treatment  of  neuralgia. 

2.  Puerperal  Neuritis  and  Paralysis. — Definition:  Puerperal  neuritis  is  a 
combination  of  neuritis  and  paralysis  which  is  single  or  multiple  and  of 
toxic  origin.  The  form  which  develops  first  during  the  puerperium  is 
believed  to  be  of  septic  origin.  It  is  also  possible  for  a  polyneuritis  of 
pregnancy  to  extend  into  the  puerperal  period.  Etiology:  While  puer- 
peral neuritis  may  depend  directly  upon  a  toxin  connected  with  some  form 
of  puerperal  sepsis,  it  is  likely  that  a  predisposition  exists  in  these  cases. 
Symptoms:  Puerperal  neuritis  may  be  general  or  localized.  The  latter  type  is 
more  common.  Localized  neuritis  may  attack  either  an  upper  or  a  lower  limb. 
Puerperal  neuritis  cannot  be  distinguished  in  any  way  from  the  non-puerperal 
type.  The  generalized  form  is  usually  a  survival  from  pregnancy,  and  is  often 
associated  with  uncontrollable  vomiting.  Its  consideration,  therefore,  belongs 
properly  to  the  Pathology  of  Pregnancy.  The  association  of  polyneuritis  with 
insanity  known  by  the  name  of  "  Korsakoff's  psychosis  "  has  been  seen  in  preg- 
nant women.  The  localized  type  of  puerperal  paralysis  is  almost  peculiar  to  the 
puerperal  period.  Its  onset  is  usually  preceded  or  accompanied  by  fever,  with 
evidence  of  neuritis,  such  as  pain  and  tenderness.  The  resulting  paralysis  may 
be  mild  and  transient,  a  mere  paresis,  or  it  may  be  of  various  grades  of  severity. 
The  affection  may  develop  early  or  late  after  delivery,  thus  recalling  the  various 
periods  of  supervention  of  the  puerperal  psychosis.  A  favorite  locality  is  the 
ulnar  or  median  nerve.  After  a  period  of  hyperesthesia,  pain,  and  tenderness 
the  sensibility  to  pain,  temperature,  and  touch  begins  to  diminish  and  motor 
insufficiency  appears  with  the  resulting  inability  to  flex  the  fingers  and  adduct 
the  thumb,  the  reaction  of  degeneration  may  develop,  and  in  severe  cases 
muscular  atrophy  develops  rapidly  in  the  ball  of  the  thumb  and  in  the  fore- 
arm.    In  rare  cases  the  nerves  supplving  the  shoulder  muscles  are  the  seat  of  the 

49 


770  PATHOLOGICAL  PUERPERIUM. 

lesion.  When  the  lower  extremities  are  involved,  the  peroneal  nerve  is  the 
favorite  site  and  a  traumatic  paralysis  is  closely  simulated.  When  paraplegia 
develops,  it  is  believed  to  be  due  to  bilateral  neuritis  throughout  the  sacral 
plexus.  This  condition  is  very  rare,  and  when  present  naturally  simulates  a 
myelitis.  Diagnosis:  The  recognition  of  a  neuritis  should  not  be  difficult.  In 
the  peroneal  nerve  the  resulting  paralysis,  however,  is  not  readily  distinguished 
from  the  traumatic  type.  Generally  speaking,  neuritic  paralysis  develops  at  a 
later  period  in  the  puerperium  with  a  history  pointing  to  an  acute  toxic  neuritis 
and  a  much  more  rapid  supervention  of  the  reaction  of  degeneration  and  mus- 
cular atrophy.  In  paraplegia  from  neuritis,  a  spinal  origin  may  be  excluded 
by  the  fact  that  the  integrity  of  the  sphincters  is  preserved.  Prognosis:  This 
depends  upon  the  character  of  the  electric  reactions,  exactly  as  in  the  traumatic 
form.  Treatment:  The  initial  neuritis  must  be  treated  by  rest,  sedatives,  a 
hypodermic  of  morphin,  and  counter-irritation.  Vinay  recommends  ergotin 
subcutaneously  at  this  stage,  one  gram  every  second  day.  When  the  neuritis 
has  subsided,  the  muscles  should  be  subjected  to  alcohol  frictions  and  massage. 
Traumatic  Paralyses. — Definition:  Traumatic  puerperal  paralyses  are 
unilateral  motor  palsies  confined  to  some  portion  of  the  distribution  of  the  sciatic 
nerve,  usually  the  peroneus,  and  due  to  compression  or  contusion  of  the  latter. 
They  belong  to  the  maternal  birth  traumatisms  and  their  existence  becomes 
apparent  soon  after  labor.  Etiology:  These  paralyses  were  originally  con- 
founded with  the  results  of  neuritis  and  other  motor  palsies  of  non-central 
origin.  Narrow  pelves  are  believed  to  furnish  a  predisposition  to  these  nerve 
traumatisms.  Other  alleged  contributory  factors  are  premature  ossification  of 
the  fetal  cranium,  unduly  prolonged  labor  and  the  arrest  of  the  head  in  the  pelvic 
excavation;  forceps  extraction,  etc.  It  is  nevertheless  true  that  these  paralyses 
may  result  after  a  labor  which  is  normal  in  every  respect.  The  great  sciatic 
nerve  is  known  to  undergo  compression  in  all  labors,  but  the  nerve-trunks  which 
traverse  the  pelvis  are  all  protected  naturally  from  undue  compression,  with  the 
exception  of  the  lumbo-sacral,  which  is  exposed  to  contact  with  the  fetal  head, 
and  especially  with  the  high  forceps  as  it  crosses  the  pelvic  inlet.  The  fact 
that  the  peroneus  branch  of  the  sciatic  nerve  is  the  seat  of  the  paralysis  in  most 
instances,  and  that  the  muscles  which  it  supplies  may  be  seen  to  contract  forcibly 
during  the  use  of  high  forceps,  is  sufficient  evidence  that  the  deleterious  pressure 
is  exerted  upon  the  lumbo-sacral  feeder  of  the  sacral  plexus  and  sciatic  nerve. 
According  to  Windscheid,*  normal  spontaneous  labor  never  causes  anything 
bej^ond  a  slight  transitory  peroneal  paralysis;  the  severe  and  perhaps  permanent 
injuries  being  traceable  always  to  forceps  or  unusual  delivery.  Symptoms :  As 
the  fetal  head  passes  the  pelvic  inlet,  the  pressure  upon  the  sacral  nerves  causes 
intense  pain  throughout  the  distribution  of  the  sciatic  nerves,  which  subsides  after 
delivery.  When  paralysis  follows,  an  interval  of  two  or  three  days  generally 
elapses  before  it  becomes  apparent.  Various  paresthesias  and  a  sensation  of  cold- 
ness may  precede  the  motor  anomalies.  When  the  latter  appear,  they  take  the 
form  of  a  paresis  of  the  thigh  muscles,  but  this  is  merely  a  transitory  forerunner 
of  the  actual  paralysis  which,  as  already  said,  tends  to  affect  the  peroneus  nerve, 
while  the  thigh  muscles  and  those  of  the  calf  retain  their  functions.  The  muscles 
antagonistic  to  the  paralyzed  group  throw  the  foot  into  an  equinus  position. 
The  electric  reactions  of  the  affected  muscles  are  normal.  The  condition  found 
is  simply  a  paralysis  of  the  tibialis  anticus,  extensor  communis  digitorum, 
extensor  hallucis  and  pedis  muscles.  When  the  patient  walks,  she  lifts  her  foot 
much  higher  than  normal  to  compensate  for  the  loss  of  power  in  the  extensors 

*  Sanger  and  von  Herff's  Encyclopaedia. 


DISEASES  OF   THE  NERVOUS  SYSTEM.  771 

of  the  foot.  The  gait  is  characteristic.  When  the  paralysis  is  of  long  standing, 
anomalies  of  sensation  are  also  present  in  the  cutaneous  area  supplied  by  the 
peroneus.  The  sensibility  to  pain,  temperature,  and  the  faradic  current  is 
more  or  less  abolished,  while  the  reaction  of  degeneration  appears  in  the  mus- 
cles. Trophic  changes  have  been  noted  in  some  cases.  Prognosis:  The  general 
outlook  in  these  cases  is  favorable.  Even  if  the  reaction  of  degeneration  appears 
in  the  muscles,  the  muscular  sense  is  usually  preserved.  Treatment:  The  patient 
should  lie  in  bed  and  have  the  affected  muscles  rubbed  and  kneaded.  If  the 
electric  contractility  is  preserved,  faradism  should  be  applied  once  daily  If  the 
reaction  of  degeneration  develops,  the  interrupted  galvanic  current  is  preferable. 

Ocular  Paralyses. — These  affections  vary  much  in  origin  and  severity. 
They  include  hemiopia,  amblyopia,  and  amaurosis.  In  regard  to  their  origin, 
they  may  be  due  to  the  occurrence  of  pregnancy-kidney,  and  belong  then  to  the 
pathology  of  pregnancy.  This  is  true  also  of  paralyses  of  hysterical  origin. 
Strictly  puerperal  ocular  paralyses  are  due  generally  to  post-partum  hemor- 
rhage, and  have  even  been  seen  after  metrorrhagia  from  abortion.  The  strictly 
puerperal  ocular  disturbances  appear  to  consist  chiefly  of  hemiopia. 

Auditory  Paralyses. — These,  as  far  as  known,  originate  during  pregnancy 
and  are  due  generally  to  nephritis. 

3.  Hemiplegia  and  Aphasia. — Definition:  Puerperal  hemiplegia  represents 
paralysis  of  one-half  of  the  body  with  or  without  implication  of  the  speech- 
center,  and  is  due  directly  to  the  puerperal  state.  Etiology:  Hemiplegia  and 
aphasia  occurring  in  the  puerperium  are  due  either  to  extravasation  of  blood  or 
to  embolism  within  the  brain,  the  latter  being  the  more  common  cause.  Ex- 
travasation of  blood  from  rupture  of  a  vessel  is  a  condition  not  likely  to  occur 
in  the  puerperium,  and  post-partum  eclamptic  convulsions  represent  about  the 
only  species  of  violence  which  can  naturally  occur  during  that  period.  Symp- 
toms: Hemiplegic  symptoms  are  doubtless  always  present  in  aphasia,  but  may 
be  so  slight  and  transitory  that  the  loss  of  speech  is  practically  the  only  affection. 
The  two  conditions  may  coexist  in  the  full  development  of  each.  Puerperal 
aphasia  is  chiefly  of  the  motor  type.  Prognosis:  When  these  affections  are  of 
hemorrhagic  origin,  the  outlook  is  grave,  although  many  patients  survive.  On 
the  other  hand,  the  prognosis  is  generally  favorable  in  the  embolic  type,  though 
fatalities  do  occur.  In  either  type  a  repetition  of  the  pregnancy  would  very 
likely  cause  a  relapse.  Treatment:  As  we  have  already  seen  that  these  puer- 
peral affections  are  made  possible  chiefly  by  eclampsia  and  sepsis,  the  preven- 
tive treatment  is  embraced  in  the  prophylaxis  of  these  evils. 

4.  Myelitis  and  Paraplegia. — Unlike  the  intracranial  affections  just  enumer- 
ated, there  is  no  evidence  that  any  of  the  various  recorded  cases  of  spinal  menin- 
gitis, myelitis,  hematomyelia,  etc.,  which  have  occurred  during  the  puerperium, 
represent  anything  beyond  simple  coincidence,  with  the  possible  exception  that 
in  a  very  few  instances  the  lesions  of  the  cord  may  have  been  due  to  puerperal 
sepsis. 

5.  Insanity  of  the  Puerperium. — Insanity  of  pregnancy  continued  into  the 
puerperal  period  hardly  belongs  to  this  category.  The  essential  puerperal 
psychoses  do  not  begin  until  several  days  after  delivery.  A  distinction  is  made 
between  the  early  and  late  puerperal  psychoses,  the  latter  appearing  toward  the 
end  of  the  puerperal  period,  or  at  the  period  in  which  the  menses  would  ordi- 
narily be  re-established.  In  regard  to  the  type  of  this  species  of  maternity- 
insanity,  it  may  be  either  maniacal  or  melancholic.  A  dementia  is  also  recog- 
nized by  alienists,  but  it  is  practically  only  a  terminal  stage  of  one  of  the  primary 
types. 


772  PATHOLOGICAL  PUERPERIUM. 

Etiology. — There  is  no  doubt  that  the  presence  of  puerperal  sepsis  in  many 
of  the  cases  is  something  more  than  a  coincidence.  AHenists  assure  us  that  since 
the  introduction  of  antisepsis  into  midwifery  the  frequency  of  puerperal  insanity 
has  been  marvelously  diminished.  Many  cases  of  this  type  of  psychosis — such 
as  is  seen,  for  instance,  in  typhoid  fever — are  said  to  exhibit  more  the  nature  of  de- 
lirium than  of  actual  insanity.  Again,  the  coincidence  of  severe  local  infection 
has  often  been  remarked,  and  gives  color  to  the  toxic  theory;  while  a  further 
coincidence  of  insanity  of  the  puerperium  with  puerperal  mastitis,  phlebitis,  and 
other  inflammations  remote  from  the  genitals  helps  justify  the  assumption  of 
this  point  of  view.  Of  other  special  contributory  factors  may  be  mentioned  the 
exhaustion  which  follows  delivery,  extreme  prostration  being  a  well-known 
cause  of  certain  psychoses  or  of  low  delirium.  In  this  connection  should  be 
mentioned  the  influence  of  post-partum  hemorrhage.  In  women  already  dis- 
posed to  insanity  the  physiological  adjustment  which  follows  child-birth  is 
doubtless  sufficient  to  set  up  mental  disorder. 

Symptoms. — According  to  alienists,  80  per  cent,  of  all  cases  of  puerperal 
psychoses  begin  within  the  first  fortnight,  and,  generally  speaking,  the  longer 
the  period  following  the  first  month  the  rarer  the  supervention  of  this  type  of 
insanity.  It  is  generally  stated  that  puerperal  insanity  is  essentially  maniacal 
in  contradistinction  to  the  insanity  of  pregnancy,  which  tends  to  the  melancholic 
type.  It  has  even  been  claimed  that  no  less  than  90  per  cent,  of  these  pyschoses 
are  maniacal  in  type.  But,  as  has  already  been  mentioned,  much  which  passes 
under  the  name  of  mania  is  hallucinatory  insanity,  and  this  is  especially  true  of 
puerperal  mania.  This  affection  supervenes  with  prodromes  of  hallucinatory 
character  which  affect  the  patient's  mind  and  cause  certain  peculiarities  of 
disposition  and  temper.  At  the  same  time  insomnia  also  develops.  Clin- 
ically the  expression  of  the  affection  comprises  an  attitude  of  suspicion  and 
hostility  to  others,  which  often  extends  to  the  person  of  the  child.  Suicidal  and 
homicidal  impulses  are  to  be  feared.  Side  by  side  with  the  mental  aberration 
we  often  see  characteristic  physical  changes,  such,  as  suppression  of  the  lochia 
and  milk,  poor  circulation,  constipation,  etc.  But  grave  affections  like  peri- 
tonitis are  sometimes  hidden  by  the  psychosis,  or,  in  other  words,  we  may  have 
to  deal  with  a  delirium  secondary-  to  some  local  infiammation  or  general  sepsis. 

Prognosis. — While  recovery  is  the  rule,  fatalities  are  by  no  means  rare,  in- 
cluding deaths  from  terminal  dementia.  In  the  fatal  cases  the  cause  of 
death  is  usually  exhaustion,  and  this  termination  is  said  to  be  common  in 
cases  which  have  the  appearance  of  acute  delirium,  due  to  some  local  or 
general  affection.  Many  cases  are  so  mild  that  recovery  ensues  after  a  good 
sleep.  In  some  instances  we  see  recurring  insanity  with  lucid  intervals,  and  a 
tendency  to  ultimate  recovery.  If  a  favorable  termination  does  not  result,  the 
case  becomes  chronic,  with  one  of  three  or  more  possible  terminations:  ultimate 
recovery  under  proper  management,  terminal  dementia,  or  paranoia, — the  two 
latter  incurable.  A  high  pulse-rate  is  a  bad  prognostic  sign  with  regard  to  early 
fatality.  The  special  prognosis  of  late  puerperal  psychoses  is  good,  although 
the  duration  is  said  to  be  longer  than  in  the  early  forms. 

Insanity  of  Lactation. — Not  much  need  be  said  of  this  type  of  maternity- 
insanity.  Psychoses  which  develop  after  the  puerperal  period  have  received 
this  designation.  They  may  be  classed,  from  the  etiological  standpoint,  as 
psychoses  of  exhaustion,  having  the  same  exciting  causes,  symptoms,  and  prog- 
nosis as  the  late  puerperal  psychoses,  from  which  they  can  with  difficulty  be 
separated. 

Treatment. — In  cases  due  to  sepsis  the  infection  must  first  be  carefully  treated 


SKIN  DISEASES— SUDDEN  DEATH  IN  THE  PUERPERIUM.      773 

(See  page  752.)  Sedatives  will  be  needed  for  the  maniacal  symptoms,  and  during 
the  whole  course  of  the  disease  the  patient  must  never  be  left  alone,  for  fear  that 
she  may  do  herself  injury.  As  in  the  insanity  of  pregnancy,  the  advice  of  an 
alienist  should  be  sought.     (Compare  Insanity  of  Gestation,  page  332.) 


XIII.   SKIN  DISEASES. 

1.  Sudamina. — This  is  a  trivial  affection  which  appears  in  infectious  diseases 
as  well  as  in  the  lying-in  period.  Vesicles  containing  a  clear,  crystal-like  fluid 
appear  scattered  over  the  abdomen.  They  are  generally  not  accompanied  by 
inflammation,  break  readily,  and  leave  a  lightly  scaling  surface.  They  owe 
their  appearance  to  a  retention  of  sweat,  the  ducts  being  blocked  by  swelling 
of  the  epidermis  which  surrounds  their  lumen.  Treatment  is  hardly  necessary, 
but  an  astringent  lotion,  such  as  calamine  and  zinc  in  lime-water,  may  hasten 
resolution. 

2.  Eruptions  of  Septic  Infection. — In  addition  to  those  diseases  which  are  due 
to  direct  infection  of  the  skin  itself,  such  as  impetigo  and  erysipelas,  there  are  a 
number  of  eruptions  caused  by  lodgment  in  the  skin  of  pus  organisms  from 
internal  foci.  Their  diagnosis  is  very  materially  aided  by  concomitant  symp- 
toms, an  infected  uterus,  the  characteristic  temperature  movement,  arthritis, 
endocarditis,  and  all  the  clinical  evidences  of  pyemia.  The  cutaneous  signs  vary 
greatly.  They  may  consist  of  an  erythema  only,  or  a  patch  of  redness  irregular 
in  outline  on  which  is  seated  a  number  of  pustules  in  various  stages  of  transforma- 
tion into  crusts.  The  erythema  may  fade  on  pressure  or  it  may  not,  owing  to 
the  presence  of  hemorrhage.  Purpura  may  be  the  only  sign.  There  is  a  septic 
pemphigus  in  which  bullae  occur  on  all  the  surfaces  except  the  palms,  soles,  face, 
and  mucous  membranes. 


XIV.   GENERAL  DISEASES. 

The  puerperal  woman  is  quite  as  susceptible  to  the  influences  of  the  general 
diseases  as  her  non-puerperal  sister,  if  not  more  so.  One  must  bear  in  mind, 
however,  that  all  such  diseases  are  modified  somewhat  by  the  peculiar  con- 
ditions of  the  puerperal  state,  and  also  that  there  is  the  possibility  in  all 
instances  of  a  mixed  infection.  These  general  diseases  have  already  been 
considered  in  the  section  on  Puerperal  Morbidity,  page  741,  Part  VII. 


XV.   SUDDEN  DEATH  IN  THE  PUERPERIUM. 

Sudden  death  during  the  puerperal  period  must  naturally  include  all  causes 
enumerated  under  the  head  of  Sudden  Death  during  Labor  (page  669),  since 
death  may  not  occur  until  after  delivery.  But  if  very  soon  after  the  com- 
pletion of  labor,  should  be  ranked  in  the  class  with  death  during  labor.  There 
are  also  some  cases  in  which  the  act  of  labor  is  not  so  likely  to  provoke  death 
as  is  the  puerperal  state.  Thus,  after  delivery  a  diabetic  patient  may  pass 
into  the  condition  of  diabetic  coma;  a  patient  with  contracted  kidneys  or  tuber- 
culosis may  develop  cardiac  paralysis,  etc.     Again,  the  mischief  may  be  due 


774 


PATHOLOGICAL  PUERPERIUM. 


primarily  to  the  act  of  labor  itself,  death  being  deferred  until  the  puerperal 
period.  In  hemorrhages  of  all  kinds  this  happens  from  the  profound  anemia 
induced  by  the  loss  of  blood.  Air  embolism  is  of  more  infrequent  occurrence, 
but  is  also  deserving  of  special  study. 

Frequency. — Sudden  death  in  the  puerperal  state  is  by  no  means  rare.  Porak 
was  able  to  report  before  a  meeting  of  the  Paris  Obstetrical  and  Gynecolog- 
ical Society  *  four  cases  which  had  occurred  within  a  relatively  short  interval. 
The  causes  were  as  follows:  chronic  heart  disease,  profound  anemia  following 
hemorrhage,  air  embolus  following  an  intrauterine  injection,  and  embolism  of 
the  pulmonary  artery. 

General  Etiology. — Conditions  of  sufficient  importance  to  require  individual 
discussion  are  shock,  heart  disease,  embolism,  air  embolism.     It  is  necessary  to 

consider  these  conditions  sep- 


VENA  CAVA 


SPERI/ATK 


HTPOCASTRIC 


OVARY 


arately  in  order  to  note  the 
various  indications  for  treat- 
ment. 

I.  Syncope  and  Shock. — 
Syncope  is  a  natural  termin- 
ation of  fatal  organic  heart 
trouble,  embolism,  air  embol- 
ism, etc.  After  excessive  loss 
of  blood  a  condition  of  syn- 
cope is  also  a  logical  pheno- 
menon. But  we  encounter 
fatal  syncope  at  times  in  pa- 
tients who  have  lost  no  blood, 
and  who  present  at  autopsy 
no  evidence  of  embolism, 
thrombosis,  or  air  in  the 
blood,  and  who  have  no  val- 
vular heart  disease.  Some  of 
these  women  doubtless  suffer 
from  a  certain  amount  of  de- 
generation of  the  myocar- 
dium. In  death  from  shock 
the  fatal  termination  does  not 
supervene  so  early  as  in  car- 
diac paralysis.  The  patient 
enters  into  a  state  of  collapse  with  rapid  and  feeble  pulse,  cold  and  moist 
skin,  pallor,  etc.  While  shock  follows  naturally  from  loss  of  blood,  operative 
intervention,  we  also  observe  it  in  physiological  labor  in  the  highly  sensitive 
woman.  The  mere  emptying  of  the  uterus  may  produce  this  condition,  doubt- 
less from  the  sudden  lowering  of  the  intra-abdominal  pressure.  Treatment: 
The  management  of  syncope  and  shock  is  practically  the  same  in  each  affection. 
Stimulants,  such  as  brandy,  ether,  strychnin,  and  camphor,  and  similar  remedies 
hypodermically  with  brandy  and  ammonia  by  the  mouth,  are  to  be  employed, 
with  nitrite  of  amyl  inhalations.  The  foot  of  the  bed  should  be  elevated  and 
the  body  surrounded  by  dry  heat.  Oxygen  may  be  administered.  It  must  be 
remembered  that  syncope  is  not  necessarily  a  dangerous  condition,  but  may  be 
little  more  than  an  ordinar}^  fainting  attack  with  a  tendency  to  spontaneous 
recovery. 

*  "  Le  Bulletin  Medical,"   Dec.  14,   1898. 


Fig.  978. — Aseptic  Thrombosis  of  the  Uterine  and 
Para-uterine  Veins  in  the  Normal  Puerperium. 


SUDDEN  DEATH  IN   THE  PUERPERIUM.  lib 

2.  Pulmonary  Embolism. — This  affection  may  occur  during  any  of  the  phases 
of  maternity:  pregnancy,  parturition,  the  puerperium,  and  the  post-puerperal 
period.  Ehology:  Pulmonary  embolism  in  the  course  of  pregnancy  is  due, 
doubtless,  to  detachment  of  a  portion  of  a  thrombus  in  a  uterine  sinus,  which 
affection  in  turn  is  to  be  attributed  to  a  partial  detachment  of  the  placenta, 
and  is  sometimes  seen  as  a  result  of  attempts  to  produce  premature  delivery. 
Embolism  after  delivery  may  also  be  attributed  in  part  to  a  uterine 
thrombosis,  but  the  development  of  a  thrombotic  state  of  the  pelvic,  iliac, 
and  crural  veins  is  doubtless  the  remote  cause  of  most  of  the  cases  of  pul- 
monary embolism  occurring  in  the  puerperium.  In  other  words,  the  predis- 
posing causes  of  pulmonary  embolism  in  the  various  phases  of  maternity  are 
comprised  under  the  head  of  the  causes  of  maternity-thromboses.  Exciting 
causes  which  determine  the  production  of  embolism  from  thrombosis  are  some- 
times evident.  The  phenomena  of  embolism  have  occasionally  followed  par- 
oxysms of  coughing,  the  act  of  rising  in  the  bed,  and  efforts  at  defecation. 
But  such  are  not  necessary  for  the  detachment  of  a  portion  of  a  thrombus.  The 
clot  of  blood  may  be  extremely  friable,  and  this  is  especially  true  in  septic  cases. 
Symptoms:  Pulmonary  embolism  expresses  itself  clinically  by  well-marked 
types,  depending  on  the  degree  of  obstruction  within  the  pulmonary  circulation. 
In  the  fulminant  or  apoplectic  type  the  patient  immediately  drops  dead.  In  a 
less  severe  type  there  is  a  brief  interval  of  irregular  pulse,  dilated  pupils,  and 
dyspnea  before  death  supervenes.  A  third  type,  while  fatal,  may  not  destroy 
life  for  some  hours.  The  symptoms  begin  with  anxiety,  a  marked  degree  of 
dyspnea,  and  restlessness,  the  patient  passing  quickly  into  a  state  of  collapse,  with 
an  icy  feeling,  and  a  vanishing  pulse.  The  mode  of  death  in  these  cases  is  acute 
pulmonary  edema.  The  preceding  types  are  necessarily  fatal  by  reason  of  the 
large  calibre  or  the  number  of  the  obstructed  vessels.  In  a  second  class  of  cases 
the  affection,  while  severe,  is  not  necessarily  fatal.  The  symptoms  agree  closely 
in  character  with  those  produced  by  shock.  There  are  a  cadaveric  pallor,  a 
pulse  barely  distinguishable,  and  extremities  of  icy  coldness.  In  a  small  pro- 
portion of  cases  premonitory  symptoms  of  embolism  occur.  Sudden  diminution 
in  the  volume  of  a  milk  leg  should  be  sufficient  to  awake  anxiety  in  the  mind 
of  the  medical  attendant.  One  obsei-ver  (von  Herff)  has  had  this  warning  in 
two  of  his  personal  cases.  Other  premonitions  have  been  noted — pain  in 
the  left  shoulder-joint,  angina  pectoris,  etc.  Diagnosis:  The  recognition  of 
pulmonary  embolism  is  often  very  difficult  or  for  an  inexperienced  practitioner 
even  impossible.  Even  experts  may  be  deceived,  and  it  is  related  that  a 
specialist  of  immense  experience  in  this  field  once  diagnosticated  pulmonary 
embolism  as  ruptured  tubal  pregnancy  with  fatal  hemorrhage.  The  symptoms 
pointing  to  the  lungs  are  not  well  defined,  for  if  the  embolism  is  sufficient  for  the 
production  of  dyspnea  and  cyanosis,  the  picture  of  collapse  develops.  If  the 
patient  is  not  destroyed  quickly  by  the  disease,  the  symptoms  of  hemorrhagic 
infarction  develop  which  should  be  easy  of  recognition.  Prognosis:  The  prognosis 
can  be  discussed  only  from  the  standpoint  of  the  chances  of  ultimate  survival 
after  the  patient  weathers  the  first  shock  of  the  disease.  (See  Hemorrhagic 
Infarction.)  Treatment:  There  is  no  treatment  for  the  fulminant  type  of  tlie 
affection.  If  the  patient  survives  the  first  onset,  she  should  be  treated  for  the 
coincident  shock  by  rest,  hot  applications,  and  cardiac  stimulants.  In  order 
to  prevent  the  deposition  of  fresh  emboli  in  the  lungs,  absolute  rest  is  indi- 
cated and  should  be  continued  for  weeks. 

3.  Primary  Thrombosis  of  the  Pulmonary  Arteries. — Embolism  from  fragments 
of  coagula  is  by  no  means  the  sole  lesion  of  this  sort  encountered  in  connection 


776  PATHOLOGICAL  PUERPERIUM. 

with  maternity,  for  primary  thrombosis  may  develop  in  the  arteries  of  the  lungs 
in  cases  in  which  puerperal  phlebitis  and  thrombus  are  absolutely  non-existent. 
In  past  years  the  question  of  the  relative  frequency  of  primary  and  secondary 
thrombosis  has  been  actively  debated.  Some  have  gone  so  far  as  to  state,  with 
Playfair,  that  the  majority  of  cases  are  primary  rather  than  secondary.  A 
third  variety  of  thrombus  may  be  due  to  clotting  in  the  right  heart,  a  detached 
portion  of  the  coagulum  plugging  the  artery;  but  practically  we  may  regard 
such  a  case  as  primary,  restricting  the  term  secondary  to  cases  in  which  the 
parent  thrombus  forms  in  a  pelvic  vein.  The  consensus  of  opinion  is  that 
primary  thrombosis  of  the  pulmonary  arteries  during  the  puerperium  is  a  rare 
occurrence,  and  that  the  great  majority  of  cases  of  sudden  death  from  obstruc- 
tion of  the  pulmonary  arteries  are  due  to  embolism.  Clinically  there  is  no 
method  by  which  primary  and  secondary  cases  may  be  differentiated. 

4.  Air  Embolism. — This  accident,  which  may  occur  either  during  or  after 
labor,  is  by  no  means  as  common  as  pulmonary  embolism  proper,  but  doubtless 
ranks  as  the  next  most  frequent  cause  of  sudden  death  in  connection  with 
maternity.  Definition:  Air  embolism  is  simply  a  form  of  pulmonary  embolism 
in  which  the  blood-vessels  are  obstructed  by  air  bubbles  which  have  found  their 
way  into  the  circulation  through  the  uterine  veins.  Etiology:  For  air  embolism 
to  occur  there  are  required  a  number  of  factors  acting  in  concert.  Air  must  have 
entered  the  uterine  cavity  from  without  (or  gas  must  have  been  formed  within) ; 
the  uterus  must  be  uncontracted;  the  uterine  sinuses  must  be  patulous;  and, 
finally,  a  certain  amount  of  air  must  have  obtained  access  to  the  circulation, 
since  the  ingress  of  a  small  quantity  may  not  give  rise  to  embolism.  For  air  to 
enter  the  uterine  sinuses  before  delivery,  the  placenta  would  have  to  be  detached 
prematurely  to  a  greater  or  less  extent.  This  accident  has  actually  happened 
before  labor  in  connection  with  attempts  to  induce  premature  delivery.  In 
cases  of  this  sort  the  relation  of  cause  and  effect  is  very  apparent ;  since  the  air 
which  is  often  injected  with  the  water  by  a  bulb  syringe  may  pass  directly 
into  the  circulation.  Air  may  doubtless  enter  the  birth  tract  from  the 
difference  in  the  pressure  within  and  without  the  abdomen,  its  ingress  being 
favored  by  a  patulous  condition  of  the  vulva,  such  as  exists  immediately  after 
delivery,  and  by  all  kinds  of  manual  and  instrumental  intervention.  The  re- 
laxation of  the  uterus  which  follows  a  pain  should  also  be  enumerated  among  the 
possible  factors  in  the  aspiration  of  air  by  the  uterus.  The  air  which  enters  the 
circulation  may  not  proceed  from  without,  since  it  may  be  generated  in  the  uterus 
as  the  result  of  the  death  and  putrefaction  of  the  fetus,  and  enter  the  veins 
only  after  removal  of  the  latter  with  the  placenta.  The  symptoms  are  entirely 
similar  to  those  of  pulmonary  embolism  in  general.  Treatm.ent:  As  in  the  case 
of  ordinary  thrombotic  embolism,  the  management  consists  in  prophylaxis  and 
in  the  treatment  of  the  pulmonary  lesion  per  se  in  case  the  patient  survives. 
Prophylaxis  consists  in  the  greatest  care  in  all  procedures  whiqh  might  possibly 
introduce  air  into  the  vagina  or  uterus,  such  as  the  induction  of  labor,  vaginal 
and  uterine  irrigations,  and  the  introduction  of  the  hand  for  various  operations 
The  secret  of  the  prophylaxis,  aside  from  the  foregoing,  is  a  firm  grasp  upon 
the  fundus  and  uterine  body  before  and  during  all  vaginal  and  uterine  manipu- 
lations. 


PART    EIGHT. 
The  Physiology  of  the  Newly  Bom* 


I.  GENERAL  PHENOMENA.  (Page  779.)  Establishment  of  Respiration, 
Changes  in  the  Fetal  Circulation.  Umbilical  Stump  and  Ring.  Tem- 
perature. Pulse.  Meconium.  Feces.  Urine.  Digestion.  Liver.  Heart. 
Blood.  Weight.  Signs  of  Normal  Nutrition.  Breasts.  Shape  of  Head. 
Sutures  and  Fontanelles. 

II.  HYGIENE  AND  MANAGEMENT  OF  THE  NEWLY  BORN.  (Page  785.)  First 
Care.  The  Bath.  Care  of  Cord.  Dressing  the  Child.  Infant  Feeding. 
(1)  Maternal  Nursing.  (2)  Wet=nurse.  (3)  Artificial  Feeding.  (4)  Pat- 
ented or  Proprietary  Foods.  Open  Air.  Sleep.  Bladder  and  Bowels.  The 
Nursery.     Environment.     Weaning. 


I.  GENERAL  PHENOMENA. 

Establishment  of  Respiration. — Until  the  fetus  has  ended  its  stay  in  uiero 
and  is  finally  expelled  into  the  outer  world,  its  lungs  are  normally  in  a  condition 
of  complete  atelectasis.  The  first  respiration,  however,  is  accomplished  as  soon 
as  the  fetus  has  entered  the  external  atmosphere.  Notwithstanding  the  many 
theories  advanced,  respiration  is  probably  not  caused  by  any  one  agent 
alone,  but  by  the  combined  influence  of  at  least  two  important  conditions 
affecting  the  respiratory  center  in  the  medulla  oblongata.  The  first  and  most 
important  is  stimulation  of  the  respiratory  center  through  the  nervous  system, 
and,  secondarily,  stimulation  of  this  center  through  changes  in  the  fetal  blood. 
For  the  sake  of  convenience  we  consider  the  latter  first.  Changes  in  the  fetal 
blood  are  brought  about  by  a  shutting-ofE  of  the  oxygen  supplied  to  the  fetus ; 
for  the  strong  and  tonic  contraction  of  the  uterus  immediately  following  fetal 
expulsion  constricts,  if  it  does  not  entirely  occlude,  the  placental  blood-vessels 
which  have  carried  on  intrauterine  respiration.  As  a  result  of  this,  the  supply 
of  oxygen  through  the  umbilical  vein,  which  has  furnished  the  fetus  an  abun- 
dance, is  cut  off.  Following  this  stoppage  a  proportionately  larger  amount  of  car- 
bonic acid  accumulates  in  the  fetal  circulation,  as,  for  the  same  reason  that  the 
oxygen  supply  is  lost,  carbonic  acid  gas  absorption  by  the  placenta  is  also  shut 
off.  Carbonic  acid  gas  greatly  stimulates  the  center  of  respiration  and  respiratory 
action  is  established.  The  cause  is  occasionally  illustrated  as  acting  singly  by  the 
efforts  of  the  fetus  to  respire  before  birth.  The  fetus  leaves  a  liquid  cushion  with 
a  temperature  of  99°  F.  and  quickly  passes  into  the  air  of  the  lying-in  room,  usually 
at  a  temperature  of  70°  F.,  or  29°  F.  lower.  This  change  produces  an  irritation 
of  the  skin,  the  shock  of  which  is  alone  sufficient  to  cause  a  reflex  action  of  the 
muscles,  and  a  stimulation  of  the  respiratory  center.  This  fact  is  illustrated 
by  our  ability  to  induce  respiratory  effort  in  cases  of  suspended  respiration  in  the 
newly  bom  by  the  skin  irritation  caused  when  we  immerse  an  infant  alternately 
in  hot  and  cold  water,  after  the  accumulation  of  carbonic  acid  gas  in  the  blood 
fails  to  stimulate  the  respiratory  center.  It  is  easy  to  conceive  of  this  mechanical 
irritation  being  alone  sufficient  to  produce  respiration,  and  therefore  that  this  is 
the  first  great  cause.  With  the  first  respiration  the  muscles  both  of  ordinary' 
and  extraordinary  respiration  are  brought  into  action,  as  shown  by  the  lusty  cry 
usually  uttered  at  the  moment  of  birth.  By  this  too,  the  chest-walls,  before 
unexpanded,*  expand  and  remain  so;  the  diaphragm  is  drawn  up,  the  muscles 
of  the  nose  and  throat  become  active,  and  the  physiological  function  of  respira- 
tion is  thoroughly  established.  The  rate  of  respiration  at  birth  varies  physio- 
logically between  40  and  45,  being  a  little  more  frequent  in  females  than  in  males, 
as  in  after  life,  and  a  little  less  frequent  in  large  robust  infants  than  in  weakly 
ones.  The  breathing  in  the  infant  is  almost  entirely  abdominal,  as  the  dia- 
phragm is  the  chief  muscle  causing  it,  the  chest-walls  and  intercostal  muscles 
taking  very  little  part  after  the  first  few  respirations,  until  later  in  life.     Auscul- 

*  According  to  Ballantyne,  rhythmic  movements  of  the  thorax  occur  in  utero.  This 
abortive  activity  may  be  due  to  a  precocious  action  of  the  respiratory  center. 

779 


780  THE  PHYSIOLOGY  OF   THE   NEWLY   BORN. 

tation  of  the  newly  bom  reveals  the  presence  of  fine  crepitant  rales  as  the  lungs 
expand. 

Changes  in  the  Fetal  Circulation. — Concomitant  with  the  establishment  of 
the  first  respiratory  action,  there  occurs  a  change  in  the  fetal  circulation,  as  the 
oxygenation  is  no  longer  carried  on  through  the  placental  circulation.  This  is 
now  accomplished  by  pulmonary  respiration  in  the  infant.  As  the  placenta  is 
now  useless,  the  functions  of  the  omphalic  vessels  no  longer  exist,  and  the  circu- 
lation connected  with  them  ceases.  In  order  clearly  to  understand  these  changes, 
it  is  important  that  the  fetal  circulation  should  be  thoroughly  understood.  (See 
page  79.)  Coincident  with  the  first  respiration  the  blood  is  diverted  from  the 
umbilical  vessels,  and  is  at  once, — by  aspiration,  as  it  were, — following  the  draw- 
ing up  of  the  diaphragm  and  expansion  of  the  chest  walls,  carried  through  the 
pulmonary  arteries  and  distributed  by  its  capillary  terminals  to  the  vessels  of  the 
lungs.  By  this  sudden  change  in  the  chief  fetal  blood-currents,  equally  important 
changes  occur  in  the  circulatory  apparatus  itself.  The  abdominal  continuations 
of  the  umbilical  vessels  close  and  by  thrombosis  and  atrophy  become  organized 
into  strong,  hard,  fibrous  cords.  There  being  no  propelling  force  of  blood  through 
the  ductus  arteriosus,  it  also  closes.  The  blood,  instead  of  being  directed  through 
the  foramen  ovale  by  the  Eustachian  valve,  now  passes  into  the  right  ventricle, 
and  hence  the  usefulness  of  the  valve  and  foramen  is  lost,  the  foramen  closes,  and 
the  valve  contracts.  From  the  right  ventricle  the  blood  is  forced  into  the  pul- 
monary artery,  and  as  there  is  no  longer  excessive  pressure  in  it — as  the  capillary 
terminals  in  the  lung  are  open — there  is  not  the  tendency  of  the  blood  to  pass 
on  into  the  aorta  through  the  ductus  arteriosus,  the  current  to  the  lungs  being 
no  longer  dammed  back  upon  the  pulmonary  artery  and  this  duct.  The  duct 
therefore  collapses  or  contracts.  By  thrombosis  here  also  organization  begins, 
and  in  later  life  the  duct  is  distinguishable  only  as  a  round  cord.  The  blood  is 
both  forced  and  aspirated  into  the  lungs  through  the  pulmonary  artery.  From 
the  lungs  it  is  returned  reoxygenated  to  the  left  auricle  through  the  pulmonary 
veins,  and  is  then  ready  to  furnish  nourishment  to  the  entire  economy.  It 
is  therefore  pumped  into  the  left  ventricle  through  the  auriculo-ventricular 
orifice,  and  thence  into  the  great  blood-main  of  the  body,  the  aorta,  whence  it 
is  distributed  through  the  branches,  terminals,  and  capillaries.  That  these 
changes  are  anticipated  during  fetal  life  is  shown  by  the  fact  that  the  ductus 
arteriosus  and  ductus  venosus  do  not  increase  in  size  in  the  same  ratio  as  the 
aorta,  venae  cavae,  etc. 

Umbilical  Stump  and  Ring. — A  line  of  demarcation  appears  at  the  base  of  the 
umbilical  stump  at  the  end  of  twenty-four  hours ;  necrosis  of  the  covering  of  the 
cord  and  mummification  of  the  jelly  of  Wharton  follow  (Figs.  979,  980,  981). 
The  remains  of  the  umbilical  vein  and  arteries  are  gradually  destroyed.  The 
line  of  demarcation  deepens  and  the  stump  falls  at  about  the  fourth  day  (Fig. 
981).  Retraction  of  the  granulating  remnant  of  stump  within  the  umbilical  ring 
follows  and  is  apparently  complete  about  the  tenth  day  (Fig.  982).  The  umbil- 
ical ring  is  merely  the  opening  in  the  abdominal  wall  around  which  the  cord 
substance  is  fastened  and  through  which  the  umbilical  vessels  pass.  There  is 
a  distinct  line  of  division  from  the  cord  substance,  about  a  fourth  to  a  third  of 
an  inch  from  the  abdominal  wall,  which  pouts  to  form  the  ring.  This  line, 
which  also  marks  the  point  of  separation  of  the  cord,  is  distinguished  from 
the  soft,  gelatinous,  pearly-white  substance  of  the  placental  end  of  the  cord  as 
a  red  ring  formed  of  a  network  of  capillary  blood-vessels  covered  by  a  very 
thin,  delicate  skin.  The  ring,  after  the  falling  off  of  the  cord  on  the  fourth  or 
fifth  day,  leaves  a  healthy  granulating  surface  which  soon  cicatrizes  (Fig.  982). 


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•     GENERAL  PHENOMENA.  781 

Owing  to  this  cicatricial  contraction  and  to  the  shortening  of  the  intra- 
abdominal remains  of  the  umbilical  vessels,  the  ring  sinks  into  the  abdominal 
wall  to  the  depth  of  a  fourth  or  a  third  of  an  inch  as  a  small,  puckered  scar, 
and  remains  thus  through  life  as  the  navel  or  umbilicus.  This  is  always  wider 
and  deeper  in  the  female  than  in  the  male. 

Temperature. — At  birth  the  fetal  temperature  varies  slightly,  averaging 
about  99.5°  to  100.5°  F.  This  is  about  0.5°  to  1°  higher  than  the  vaginal  tempera- 
ture of  the  mother.  It  is  what  would  be  expected,  as  the  fetus  has  been  en- 
compassed in  the  uterus  by  a  liquid  cushion  at  the  internal  maternal  temperature 
of  99°  F.,  which  can  take  up  very  little  of  the  temperature  of  the  fetus,  as 
radiation  from  this  liquid  must  be  slight.  Hence  the  metabolic  changes  occur- 
ring in  the  growing  fetus  are  sufficient  to  keep  its  temperature  about  1°  F.  higher 
than  the  maternal  temperature.  Soon  after  birth  the  temperature  has  fallen 
about  1.8°,  but  again  reaches  the  normal  infant  temperature  of  99.4°  F-  in  about 
twenty-four  hours.  The  temperature  varies  irregularly  during  the  first  few 
weeks  of  life,  being  elevated  sometimes  even  0.5°  by  prolonged  and  vigorous  cry- 
ing, and  dropping  0.6°  to  1°  during  sleep. 

Pulse. — The  pulse-rate  in  the  newly  born  varies  between  130  and  140  per 
minute,  depending  upon  the  activity  and  robustness  of  the  child,  also  being 
slightly  faster  in  a  healthy  female  than  in  a  male.  As  has  been  stated,  the  respi- 
rations are  much  more  rapid  and  shallower  in  the  infant  than  in  later  life,  and 
the  temperature  is  higher.  An  increased  pulse-rate  would  consequently  result. 
This  rate  varies  greatly  physiologically,  being  increased  from  20  to  30  beats  per 
minute  by  muscular  activity  from  any  cause,  such  as  crying  or  being  raised 
from  the  recumbent  to  the  upright  posture.  Great  excitement  sometimes 
increases  its  frequency  and  also  its  force.  It  may  in  perfect  health,  especially 
when  very  rapid,  be  very  irregular  physiologically.  As  throughout  life,  it 
varies  in  proportion  to  the  respirations  and  temperature,  though  much  more 
irregularly. 

Meconium ;  Feces. — A  study  of  the  stools  in  infancy  is  valuable  not  only  on 
account  of  the  information  it  gives  concerning  the  alimentary  processes,  but  also 
because  it  determines  in  a  great  degree  the  necessary  strength  and  quantity  of  the 
infant's  food.  Besides,  it  aids  us  in  determining  the  nature  of  many  of  the 
disturbances  so  frequent  at  that  period  of  life.  The  newly  bom  infant  passes 
stools  greenish-black  in  color,  known  as  meconium,  composed  of  mucus,  bile, 
vernix  caseosa,  epithelium,  hair,  fat  crystals,  phosphates,  and  bacteria.  After  the 
fourth  or  fifth  day  the  stools  of  a  baby  fed  upon  milk  alone,  whether  from  breast 
or  bottle,  should  be  yellowish,  pasty  in  consistency,  of  acid  reaction,  and  not 
disagreeable  in  odor.  The  color  is  due  to  bilirubin  and  the  reaction  to  lactic 
acid,  the  source  of  which  is  the  milk  sugar.  Mucus  and  epithelium  are  always 
present.  Miller,  who  has  carefully  studied  the  various  micro-organisms  in  the 
mouth,  found  that  the  majority  of  them  could  again  be  located  in  the  intestinal 
canal.  In  the  feces,  two  germs.  Bacterium  lactis  aerogenes  and  Bacterium  coli 
commune,  are  the  most  important.  In  the  first  two  weeks  the  stools  number 
from  three  to  six  each  day;  after  the  first  month  they  vary  from  one  to  three 
daily — the  average  being  two  each  day.  Later  in  infancy,  when  other  articles 
are  added  to  the  milk  diet,  the  stools,  while  remaining  soft  and  watery,  become 
darker  in  color  and  contain  a  greater  variety  of  bacteria.  The  gases  present  are 
hydrogen  (H)  and  carbon  dioxide  (CO.),  the  adult  odor  being  acquired  later, 
due  to  the  presence  of  hydrogen  sulphide  (H.S).  The  bulk  of  the  stool  is  com- 
posed of  about  85  per  cent,  water,  and  fat  varying  in  amount  from  2  to  4  per 
cent.     Pathologically  the  stools  may  assume  one  of  a  variety  of  colors  and  con- 


782  THE  PHYSIOLOGY  OF   THE  NEWLY   BORN. 

tain  any  of  a  long  list  of  materials.  Green  stools  are  of  very  frequent  occurrence. 
When  very  acid  or  thin,  they  often  cause  irritation  of  the  buttocks  and  are 
accompanied  by  colic.  The  green  color  is  due  to  pre-formed  bilirubin.  These 
stools  usually  contain  more  or  less  undigested  casein  and  fatty  acids.  Stools 
varying  in  color  from  pale  greenish-yellow  in  the  early  stages  to  grass  green  later, 
are  seen  in  cases  of  acute  intestinal  indigestion,  the  result  of  improper  feeding 
An  excess  of  sugar  causes  thin,  acid,  green  stools.  Bismuth,  tannic  acid,  and 
the  iron  salts  color  the  stools  from  deep  brown  to  black.  Blood  gives  the  char- 
acteristic tarry  stool  when  the  blood  is  admixed  higher  up  in  the  intestinal 
canal;  when  lower  down,  it  is  brighter  red  in  color.  An  excess  of  mucus  indi- 
cates some  inflammatory  condition  of  the  large  intestine.  Light  or  light  gray 
stools  of  a  pasty  consistency,  or  in  dry  balls,  contain  an  excess  of  fat  and  are 
usually  offensive  in  odor.  When  proteids  are  in  excess  or  too  much  food  is 
given  at  a  time,  curds  appear  in  the  stools,  sometimes  with  diarrhea,  but  more 
often  with  constipation  and  colic.  Curds  are  especially  liable  to  occur  in  infants 
fed  upon  cow's  milk,  particularly  when  sterilized. 

Urine. — As  a  rule,  almost  immediately  after  birth  the  infant  voids  urine 
at  or  just  before  the  time  it  passes  meconium.  It  is  of 
a  slightly  urinous  odor,  aqueous  in  color,  markedly  acid, 
specific  gravity  1004  to  loio,  containing  an  unusual 
amount  of  albumin  in  t,7,  per  cent,  of  cases,  a  few 
granular  and  numerous  hyaline  casts,  an  inordinate 
amount  of  uric  acid,  and  frequently  some  sugar.  These 
^^^.  ?f  ^tTT.Vc^^^^  rSf  ^J     are  all  characteristics  of  the  urine  of  the  newlv  born. 

TRAL     iNCISOR      1  OOTH  .  - 

Extracted  with  In  a  short  time,  varying  from  three  days  to  three  months, 
Thumb-forceps  from  these  change.  In  about  three  days  the  specific  grav- 
AN^NFANT  ^^^^  ^Ys  ^^^  drops  to  from  1003  to  1006,  the  albumin  disappears 
terfered  with  nursing  with  the  casts,  epithelium,  and  excessive  mucus  ob- 
by  causing  an  erosion  served  at  first.  The  urine  is  passed  frequently  during 
at  the  Eimrgency  Hos-  ^^^  waking  hours,  but  less  frequently  during  sleep. 
pital.)  Normal  urine  should  not  stain  the  napkin. 

Digestion. — As  milk  contains  all  the  nutritive  prin- 
ciples found  in  the  various  foods  ingested  by  the  adult,  we  would  expect  to  find 
in  the  infant  the  numerous  digestive  agents  necessary  in  adult  life,  and  such  is 
the  case,  though  they  are  present  in  smaller  quantities.  Besides  these,  there  is 
in  the  stomach,  in  proportionately  larger  quantity  than  in  adults,  a  ferment 
especially  adapted  to  the  infant  food,  known  as  the  rennet  ferment,  the 
action  of  which  is  to  curdle  milk  on  its  entrance  into  the  stomach.  As  the 
milk  rapidly  passes  through  the  mouth  during  nursing,  there  is  very  little 
use  for  saliva,  with  its  power  of  changing  starch  into  sugar.  The  milk 
having  been  sucked  into  the  mouth,  it  is  swallowed  at  once.  Owing  to  the 
small  amount  of  saliva,  and  consequently  of  ptyalin,  and  also  of  the  deficiency 
of  the  pancreatic  secretion,  provision  for  the  digestion  of  starches  is  lacking 
in  young  children.  The  practical  application  of  this  fact  will  be  noted  in  con- 
nection with  infant  feeding.  With  the  above  exception  infantile  digestion  is 
accomplished  in  the  usual  way.  It  is  aided,  however,  by  the  presence  of  bac- 
teria in  the  alimentary  canal.  As  soon  as  milk  enters  the  stomach  the  rennet 
ferment  causes  a  soft  flocculent  curd  to  be  formed.  This  is  the  chief  part  of 
gastric  digestion  in  the  infant,  as  the  pepsin  and  hydrochloric  acid  begin  to 
digest  this  curd  only  when  it  is  passed  on  into  the  intestine.  It  will  be  remem- 
bered in  this  connection  that  in  the  newly  bom  the  stomach  serves  more  the 
part  of  a  reservoir  than  of  a  digestive  organ.     The  proteids  have  been  partially 


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GENERAL  PHENOMENA. 


783 


Fig.  988. — Two  Middle 
Lower  Incisors.  Ap- 
pear third  to  tenth 
month;  average, 
seventh  month. 


changed  into  peptones  and  some  absorption  has  taken  place.  Having  been 
poured  into  the  intestinal  tract,  the  milk  is  here  brought  in  contact  with  the  pan- 
creatic secretion,  which  contains  all  the  ferments  necessary  for  converting  more 
completely  the  proteids  into  peptones,  for  emulsifying  fats,  and  for  changing 
starch  into  sugar.  Here,  too,  it  is  brought  in  contact  with  the  bile  from  the 
liver,  which  further  helps  to  emulsify  the  fats.  These  fats  are  principally 
absorbed  from  the  small  intestine,  as  are  also  the  peptones,  salts,  and  sugar;  the 
glands  of  the  large  intestine  are  as  yet  imperfectly  developed,  hence  its  absorb- 
ing power  is  slight. 

Liver. — At  birth  it  is  well  to  remember  the  very  large  size  of  the  liver  in 
proportion  to  the  body,  it  being  about  one-thirtieth 
the  entire  body-weight.  This  is  readily  understood 
when  it  is  remembered  that  the  liver  and  the  head  are 
nourished  in  fetal  life  by  the  practically  pure  freshly 
oxygenated  blood,  and  consequently  these  parts  are  well 
developed.  Immediately  after  birth  the  secretion  of 
bile  is  lessened  because  of  the  diminished  blood-supply  to 
the  liver.  Pressure  upon  the  hepatic  veins  is  lessened. 
During  exfoliation  of  the  stump  of  the  cord  the  capsule 
of  Glisson  may  become  swollen. 

Heart. — At  birth  the  heart  is  relatively  larger  in  com- 
parison with  the  body-weight  than  at  any  other  time  of 
life.  The  walls  of  the  two  ventricles  are  found  to  be 
nearly  of  the  same  thickness,  for  the  two  sides  of  the 
heart  have  been  doing  about  the  same  amount  of  work. 
At  birth  the  work  thrown  upon  the  left  ventricle 
is  greatly  increased,  in  comparison  with  the  right, 
hence  the  left  increases  in  thickness  more  rapidly,  and 
later  in  life  we  find-  that  it  has  reached  the  proportion 
of  about  2  :  i  instead  of  about  6  :  7  as  at  birth.  The 
heart's  action  is  much  more  frequent  at  birth  than 
later,  being  also  more  frequent  and  less  regular  in 
females  than  in  males.  Its  position  is  not  so  oblique  as 
in  the  adult.  The  apex  impulse  is  farther  to  the  left 
than  later  in  life,  and  usually  for  the  first  few  days  is 
just  outside  the  mammary  line  in  the  fourth  intercostal 
space.  The  sounds  are  much  louder  comparatively 
than  in  adult  life,  owing  to  the  thinness  of  the  chest- 
walls  and  the  greater  area  of  cardiac  dulness — the  lung 
not  overlapping  the  heart  to  so  great  an  extent. 

Blood. — At  birth  the  proportionate  amount  of  blood 
is  less  than  in  the  adult,  averaging  about  iV  the  body-weight,  while  later  in  life  it 
is  about  xV-  This  varies  in  the  newly  bom,  depending  largely  upon  the  time 
when  the  umbilical  cord  is  tied.  In  immediate  ligation  the  weight  may  be 
only  Ys,  while  if  ligation  is  postponed  until  cessation  of  pulsation  in  the  cord  it 
may  be  even  greater  proportionately  than  in  the  adult,  often  being  as  high  as 
tV  the  body-weight.  While  the  specific  gravity  and  hemoglobin  are  higher,  and 
the  proportionate  number  of  red  and  white  cells  is  greater,  and  the  proportion 
of  white  cells  to  red  is  also  increased, — about  i  :  160, — the  blood  is  thinner, 
more  watery,  contains  less  fibrin,  and  therefore  does  not  coagulate  or  clot  so 
readily  as  adult  blood.  There  is  also  a  much  greater  variation  in  the  size  and 
appearance  of  the  blood-corpuscles,  as  the  blood-glands  continue  to  form  new 
cells  in  greater  quantities  for  about  three  days. 


Fig.  989. — Four  Upper 
Incisors.  Appear 
ninth  to  sixteenth 
month. 


Fig.  990. — Order  op 
THE  Eruption  op  the 
Eight  Incisors  (Milk 
Teeth). 


784  THE  PHYSIOLOGY  OF   THE  NEWLY   BORN. 

Weight. — At  full  term  an  average  fetus  weighs  about  7.3  pounds.  The 
weight  varies  largely,  as  would  be  expected,  depending  on  numerous  influences 
which  it  is  well  to  mention:  (i)  Depending  upon  the  parents,  (a)  The  size  of 
the  parents  seems  to  influence  somewhat  the  size  of  the  infant;  infants  bom  of 
parents  of  large  stature  are,  on  an  average,  larger  than  those  whose  parents  are 
small,  (i)  Strong,  healthy  parents  may  also  expect  larger  children  than  do  those 
in  feeble  health,  (c)  The  age  of  the  mother  seems  to  influence  the  size  of  the 
infant, — women  between  twenty-four  and  thirty-four  bearing  the  largest  children, 
as  this  is  the  prime  of  motherhood,  {d)  Parity.  The  offspring  of  primiparae 
average  less  in  size  and  weight  than  those  of  multiparge.  Also,  each  fetus  seems 
to  weigh  a  little  more  than  the  preceding  one  when  sufficient  time  elapses  be- 
tween births,  {e)  Frequency  of  child-birth  greatly  influences  the  size  of  the 
fetus,  as  in  pregnancies  rapidly  following  one  another  each  succeeding  child 
is  less  robust.  (2)  Sex.  Males  average  a  greater  weight  than  females.  There 
is  for  three  days  a  continuous  loss  in  weight,  due  partly  to  the  frequent 
discharge  of  urine  and  feces,  but  largely  to  the  excess  of  tissue  waste  over 
tissue  reconstruction.  This  averages  about  11  per  cent,  of  the  body -weight. 
The  weight  is  gradually  regained,  however,  from  the  third  day  on,  and  by  the 
tenth  day  has  reached  the  weight  at  birth.  This  steady  increase  should  there- 
after continue  uninterruptedly  in  a  healthy  child. 

Signs  of  Normal  Nutrition. — The  end  of  the  first  week  of  life  generally  finds 
an  infant  at  the  weight  accredited  to  it  at  birth;  the  slight  loss  attendant  upon 
the  elaboration  of  the  mother's  milk  during  the  first  three  or  four  days  is  made 
up  at  the  end  of  the  first  week.  After  this  period  the  weight  of  a  properly 
,  developing  infant  will  increase  from  6  to  8  ounces  each  week,  or,  roughly  speak- 
ing, an  ounce  a  day  for  the  first  two  or  three  months.  At  the  end  of  the  fifth  or 
sixth  week  this  gain  is  slightly  lessened,  but  it  is  steady.  Taking  seven  pounds 
as  the  average  weight  of  an  infant  at  birth,  it  should  weigh  fourteen  pounds  at 
the  end  of  the  first  five  months  and  twenty-one  pounds  at  the  end  of  the  first 
year. 

TABLE  SHOWING  THE  GAIN  IN  A  HEALTHY  INFANT  FED  AT  THE  BREAST 

Normal  weight  at  birth,  7  lbs  Gain  at  end  of  first  week,  none. 
Weight  when  2  weeks  old,  7  lbs.    6  oz.  "  "       2d         "     6  oz. 

3       "         "7  lbs.  14  oz.  "  "        3d         "      8  oz. 

"  "      4       "         "8  lbs.     6  oz.  "  "       4th        "      6  oz 

In  a  breast-fed  infant  when  the  weight  does  not  increase,  the  milk  should 
be  examined  to  determine  which  ingredient  is  at  fault.  Any  failure  to  gain 
steadily  in  a  baby  fed  upon  modified  milk  warrants  a  change  either  in  the  quan- 
tity or  the  strength  of  its  food.  Besides  the  gain  in  weight,  which  emphasizes 
more  strongly  than  any  other  factor  that  the  baby  is  thriving,  its  general  con- 
dition, whether  it  is  comfortable,  its  sleep  quiet  and  sufficient,  the  stools,  with 
their  number,  color,  and  consistency,  should  be  taken  into  consideration.  It 
is  not  a  rapid  but  a  steady  gain  in  weight  which  is  all-important. 

Breasts. — At  birth  the  breasts  of  the  infant  are  sometimes  found  to  be  com- 
paratively large,  swollen,  and  secreting.  This  secretion  is  greatest  usually  at 
the  end  of  the  first  or  beginning  of  the  second  week.  At  this  time  the  glands 
are  increased  in  size,  red,  with  elevation  of  temperature,  rather  hard,  and  very 
sensitive.  The  vessels  are  turgid  and  the  whole  merely  presents  a  picture  of  a 
functionating  gland  (Fig.  970).  Normally  this  secretion  continues  only  for 
about  two  weeks,  but  may  be  found  much  later,  the  secretion  itself  being  about 
the  same  in  appearance  as  the  mother's  milk.     The  amount  of  secretion  is  the 


HYGIENE  AND_  MANAGEMENT  OF  THE  NEWLY  BORN.         785 

same  in  the  two  sexes,  it  being  merely  a  physiological  gland  activity.  No  harm 
commonly  results,  but  all  manipulation  or  attempts  to  express  secretion  should 
be  forbidden,  since  they  may  result  in  the  development  of  an  abscess.  (See  Part 
IX.) 

Shape  of  Head. — After  moderate  moulding  during  labor,  the  head  usually 
resumes  its  normal  shape  in  four  or  five  days.  In  the  excessive  moulding  of  per- 
sistent occipito-posterior  positions,  in  temporary  mento-posterior  positions,  and 
in  presentation  of  the  anterior  parietal  bones  (Naegele's  obliquity)  a  return  to  the 
normal  contour  may  be  delayed  as  long  as  two  weeks  or  more.  I  have  tracings 
of  the  head  taken  at  birth  in  the  first  and  second  of  the  above  positions,  and  also 
one  and  two  weeks  after  delivery,  showing  the  tardy  return  to  the  normal.  The 
caput  succedaneum  rapidly  disappears  even  when  extensive.  Change  in  shape 
largely  due  to  a  cephalohematoma  may  persist  for  two  or  three  weeks,  or  until 
the  blood-clot  is  absorbed.     (See  Part  IX.) 

Sutures  and  Fontanelles. — The  edges  of  the  cranial  bones  are  normally  in 
apposition  at  birth.  Separation  is  commonly  due  to  prematurity,  syphilis,  or 
rachitis.  Ossification  does  not  usually  occur  until  the  end  of  the  sixth  month 
or  later.  The  posterior  fontanelle  is  usually  closed  about  the  end  of  the  second 
month  and  the  anterior  about  the  eighteenth. 

Post-mortem  Observations. — These  in  the  infant  should  include  (i)  the  rela- 
tively large  size  of  the  thymus  gland  and  heart;  (2)  whether  the  thymus  ob- 
structs the  trachea;  (3)  whether  the  lungs  are  inflated  and  overlap  the  heart; 
(4)  the  relatively  large  size  of  the  bladder,  sigmoid  flexure,  appendix,  and 
liver;  (5)  infection  of  the  hypogastric  arteries  from  a  septic  umbilical  ring. 


II.  HYGIENE  AND  MANAGEMENT  OF  THE  NEWLY  BORN. 

First  Care  of  the  Infant. — After  the  cord  has  been  tied  and  cut  and  the  eyes 
have  been  washed  with  a  solution  of  boric  acid,  the  baby  should  be  wrapped 
in  a  soft,  warm  piece  of  flannel,  laid  in  some  convenient  place  out  of  harm's 
way,  and  covered  with  a  shawl  or  other  covering,  taking  care  to  allow  sufficient 
breathing  space.  Here  it  may  remain  till  the  mother  has  received  proper 
attention.  It  should  occasionally  be  noted  that  the  respirations  are  regular 
and  that  there  is  no  oozing  from  tne  cord  (page  489). 

The  Bath. — After  making  the  mother  comfortable  the  nurse  may  attend  to 
bathing  the  child.  The  necessary  articles  have  been  provided  and  stand  ready 
for  use,  in  winter  near  a  fire  or  register.  They  consist  of  a. small  tub  or  bowl 
of  water  at  95°  to  100°  F.,  a  soft  rag,  and  a  warm,  soft  towel.  The  nurse  should 
wear  a  flannel  apron  or  may  have  a  flannel  apron  or  petticoat  spread  over 
her  lap.  The  vernix  caseosa  is  miscible  with  sweet  oil  and  is  best  removed 
by  a  free  use  of  oil.  The  infant  is  then  gently  sponged  with  a  soft  cloth  and 
tepid  water.  Only  a  small  part  of  the  body  is  bathed  at  a  time,  the  rest  being 
kept  covered.  The  bathing  is  done  in  the  warmest  part  of  the  room,  before 
the  stove,  register,  or  best  an  open  fire.  All  manipulations  should  be  gentle, 
and  feeble  or  premature  children  should  not  be  washed,  the  vernix  being  cau- 
tiously removed,  care  being  taken  that  the  surface  does  not  become  chilled.  It  is 
better  not  to  give  a  tub-bath  till  the  tenth  day,  as  it  is  something  of  a  shock, 
and  its  repetition  tends  to  prevent  healing  and  desiccation  of  the  umbilicus 
and  may  result  in  infection.  The  usual  tendency  is  toward  too  much  bathing, 
scrubbing,  and  exposure.  During  the  first  ten  days  the  child  should  be  cleansed 
50 


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786  THE  PHYSIOLOGY   OF   THE   NEWLY   BORN. 

daily  as  above  described.  Soap  should  be  used  moderately,  and  chiefly  about 
the  genitals  and  axillas.  Fine  castile  soap  is  to  be  preferred.  Powders  are 
unnecessary  except  about  the  genitals  and  flexures  of  the  joints  and  folds  of 
skin;  powdered  starch,  talc,  or  lycopodium  may  be  used. 

Care  of  Cord. — The  cord  should  be  dusted  with  a  non-toxic  antiseptic  or 
aseptic  powder,  as  pulverized  boric  acid  or  sterile  starch,  wrapped  in  borated 
absorbent  cotton,  and  kept  as  dry  as  possible.  Since  septic  infection  may  occur 
at  the  umbilicus,  the  nurse  should  carefully  disinfect  her  hands  before  touching 
this  region.  After  separation  of  the  cord  the  umbilicus  should  be  kept  per- 
fectly clean,  but  not  washed  more  than  necessary,  and  should  be  dusted  with 
powdered  boric  acid  or  sterile  starch. 

Dressing  the  Child. — The  infant's  clothing  should  be  warm,  loose,  easily  re- 
moved, and  not  irritating.    The  band  is  unnecessary,  and  when  pinned  as  tightly 

as  is  often  done,  is  decidedly  injurious  by  interfering 
with  respiration  and  leading  to  defective  develop- 
ment of  the  abdominal  wall.  If  used,  it  should  be 
applied  loosely,  should  be  of  flannel  or  knitted  wool, 
and  should  extend  from  the  pubis  to  the  axillary 
region.  The  undershirt  should  be  of  soft  flannel, 
with  high  neck  and  long  sleeves,  and  buttoned  all 
the  way  so  that  it  can  easily  be  removed.  The 
dress  should  be  of  flannel,  twenty-five  inches  from 
neck  to  hem,  opening  in  front;  over  which  may 
be  worn  a  muslin  slip,  opened  behind  if   desired. 

■p  -n    ^„.,,  oT,^„/      Long  woolen  socks  should  be  added  and  the  baby 

Fig.    991. — Diagram    show-      .        =>         ,        _.  r     ^ -,        r     ,- 

iNG  Sterile  Gauze  Dress-     is  dressed.     Diapers  should  be  of  old  soft  Imen  or 
iNG  FOR  Umbilical  Cord.       cotton  diapering;  they  should  not  be  hemmed,  as 

this  makes  little  ridges.  They  should  be  rough 
dried,  as  ironing  makes  them  hard  and  less  absorbent.  They  should  be 
changed  as  soon  as  wet  and  not  used  again  without  washing.  If  used  without 
washing,  they  cause  chafing.  Infants  are,  as  a  rule,  too  warmly  clad  in 
summer.  The  amount  and  quality  of  the  clothing  should  be  changed  accord- 
ing to  temperature,  so  that  sudden  chilling  of  the  surface  may  be  avoided. 
In  cold  weather  it  is  necessary  to  protect  the  baby  thoroughly,  but  if  the 
house  is  kept  at  the  average  temperature  of  American  homes,  a  more  decided 
difference  than  usual  should  be  made  between  the  indoor  and  outdoor  garments. 


INFANT  FEEDING. 

I.  Maternal  Nursing. — After  delivery  is  completed  and  the  abdominal  binder 
is  applied  the  patient  must  be  allowed  a  number  of  hours  of  sleep,  after 
which  the  child  may  be  placed  at  the  breast.  The  suction  exerted  by  the 
infant  at  this  time  favors  the  contraction  of  the  uterus,  assists  in  the  formation 
of  the  first  milk,  and  abstracts  the  colostrum  from  the  breasts.  The  latter 
substance  is  supposed  to  exert  a  favorable  influence  on  the  digestive  apparatus 
of  the  infant.  Whenever  possible  the  mother  should  nurse  her  own  child, 
since  the  nutriment  thus  supplied  is  unquestionably  the  most  natural  and 
wholesome  food  in  the  earliest  period  of  life,  and  it  can  be  proved  that  involution 
is  more  satisfactory  in  women  who  nurse  their  children.  Unfortunately,  this 
is  not  always  possible  for  a  variety  of  reasons,  some  of  which  are  due  to 
the  strain  of  modern  civilization  and  abnormal  environment,  others  of  which 


HYGIENE  AND  MANAGEMENT  OF  THE  NEWLY  BORN. 


787 


depend  upon  deformity  or  disease  on  the  part  of  the  mother  or  child.  Some 
of  the  most  important  conditions  are,  on  the  part  of  the  mother,  syphilis,  phthisis, 
mammary  abscess,  marked  anemia,  and  depressed  or  absent  nipples;  and,  on 
the  part  of  the  child,  harelip. 

The  secretion  of  milk  is  usually  established  in  the  second  twenty-four-hour 
period  after  delivery,  and  it  is  not  necessary  to  supply  any  form  of  nutriment 
to  the  child  before  the  expiration  of  that  period,  except  what  it  gets  from  the 
breast.  Warm  water,  however,  should  be  freely  administered.  It  is  a  mistake 
to  give  milk  and  water,  sugar-water,  or  any  artificial  food  during  this  period ; 
though  if  proper  milk  secretion  is  not  established  by  the  beginning  of  the  third 
day,  it  may  be  necessary  to  begin  artificial  feeding  at  least  temporarily.  Even 
in  the  first  two  days  of  life  it  is  practicable  to  feed  infants  with  a  modified 
milk  containing  a  very  low  percentage  of  proteids,  about  0.25  to  0.5  per  cent. 
Such  infants  do  not  lose  weight,  as  is  often  the  case  when  all  food  is  withheld 
for  this  time.  (See  Treatment 
of  Prematurity,  page  802.) 
When  the  flow  of  milk  is  prop- 
erly established,  the  child  must 
be  trained  to  nurse  at  regular 
intervals,  and  it  must  not  be 
put  to  the  breast  every  time  it 
cries.  The  proper  intervals  vary 
somewhat  according  to  the  age 
of  the  child,  and  may  be  roughly 
estimated  as  follows:  Up  to  the 
age  of  six  weeks,  every  two 
hours  between  6  a.m.  and  10 
P.M.,  and  one  feeding  between 
10  P.M.  and  6  a.m.;  from  six 
weeks  to  four  months,  every 
two  and  a  half  hours,  with  one 
night  feeding;  from  four  to 
nine  or  ten  months,  every  three 
hours,  without  any  feeding  be- 
tween 10  p.m.  and  6  a.m.  Water 
may  be  given  occasionally  be- 
tween feedings.  Each  breast  must  get  its  share  of  use,  and  it  is  best  to 
alternate  regularly.  The  child  should  be  allowed  to  nurse  for  fifteen  or 
twenty  minutes  and  no  longer.  Irregularity  in  feeding  is  a  prolific  cause  of 
indigestion  and  flatulence  in  the  infant,  and  is  often  the  cause  of  maceration 
of  the  nipple,  besides  being  a  great  annoyance  to  the  mother.  If  the  child 
shows  an  inclination  to  nurse  longer  than  twenty  minutes,  it  indicates  that 
there  is  a  deficient  supply  of  milk  in  the  breast.  Failure  to  nurse  satisfac- 
torily may  be  caused  by  placing  the  child  in  such  a  position  that  it  cannot 
secure  a  proper  hold  on  the  breast  and  has  to  seize  the  nipple  obliquely,  or 
the  child's  nose  may  be  pressed  so  closely  against  the  breast  that  breathing 
may  be  interfered  with  and  thus  satisfactory  nursing  becomes  impossible. 
These  are  matters  very  easily  regulated,  and  though  apparently  insignificant, 
should  never  be  neglected.  The  physician  shovild  satisfy  himself  by  actual 
observation  that  all  is  being  done  properly,  since  carelessness  and  lack  of 
knowledge  are  all  too  common. 

The  average  composition  of  average  normal  human  milk  is  put  down  thus :  fat 


Fig.  992. — Baby  Scales. 


788 


THE  PHYSIOLOGY  OF   THE  NEWLY  BORN. 


4.00;  sugar,  7.00;  proteids,  1.50;  alkaline  reaction  and  no  bacteria.  Variations 
occur  frequently,  but  between  moderate  limits  are  not  significant  and  do  not  dis- 
turb the  infant's  digestion.  The  quantity  of  milk  raay  be  increased  by  attention 
to  the  general  health  of  the  mother  and  by  allowing  plenty  of  fluids.  Cathartics 
and  curtailment  of  fluids  have  the  opposite  effect.  Malt  preparations,  milk, 
and  gruel  seem  to  have  a  special  faculty  of  increasing  the  milk-supply.  The 
quality  of  the  milk  may  vary  from  over-rich  to  bad.  Too  much  rich  food, 
improper  habits  of  life,  and  insufficient  exercise  will  cause  the  milk  to  contain 
too  high  a  proportion  of  solid  ingredients,  the  chief  disturber  of  the  infantile 
digestion  being  the  increase  of  proteids.  The  remedy  for  the  condition  is 
obvious.  A  poor  milk  usually  contains  too  much  proteid  and  a  subnormal 
amount  of  sugar  and  fat,  while  a  bad  milk  accentuates  this  disproportion. 
Overwork  and  improper  diet  will  cause  the  milk  to  be  poor,  while  the  causes 
of  the  production  of  a  bad  milk  are  usually  put  down  as 
neurotic. 

2.  Wet-nurse. — The  best  substitute  for  the  milk  of 
the  mother  is  the  milk  of  a  healthy  woman  who  is 
nursing  a  child  of  about  the  same  age  as  the  infant  she 
is  to  feed.  To  be  a  desirable  wet-nurse,  a  woman  should, 
in  addition  to  having  a  child  of  about  the  same  age  as 
the  child  she  is  to  nurse,  be  free  from  any  communicable 
disease,  such  as  tuberculosis,  syphilis  or  gonorrhea;  she 
should  have  a  good  quantity  of  milk  and  the  nipples 
should  be  normal  in  development  and  general  condition. 
If  possible,  her  child  should  be  examined  for  evidences 
of  syphilis,  which  when  it  occurs  is  sometimes  more 
evident  in  the  child  than  in  the  mother.  Until  the 
character  of  the  nurse  is  proved,  she  should  be  watched 
while  she  is  nursing  the  child,  and  if  all  goes  well,  the 
result  will  be  as  good  as  if  the  child  were  nursed  by  its 
mother.  The  diet  of  the  nurse  will,  of  course,  require 
supervision,  and  in  many  cases  it  will  be  necessary  to 
guard  against  overindulgence  in  malt  liquors.  There 
is  no  more  difficult  or  thankless  task  than  the  procuring 
and  supervision  of  a  wet-nurse,  and  she  has  been  defined 
by  some  one  "as  one  part  cow  and  nine  parts  devil." 
-This  must  be  resorted  to  when  the  mother  cannot  nurse 
It  is  only  when  maternal  nursing  is 


Fig.  993.  —  Materna 
Graduate  Glass  for 
Artificial  Infant 
Feeding. 


3.  Artificial  Feeding. 

her  child  and  a  wet-nurse  is  not  available, 
impossible  or  when  it  presents  conditions  which  are  unsuitable,  such  as  when  the 
milk  is  unreliable  in  quantity  and  too  poor  in  quality  properly  to  nourish  the  child, 
that  artificial  feeding  should  be  resorted  to.  Breast-milk  practically  does  not 
change  its  composition  during  a  normal  lactation,  but  it  has  been  observed 
that  infants  cannot  take  so  rich  an  artificial  food  as  a  natural  one,  and  it  is 
necessary  to  alter  the  proportion  of  some  ingredient  in  preparing  the  artificial 
food.  In  certain  cases  the  woman  can  supply  a  portion  of  the  milk  required 
by  the  infant  and  the  deficiency  must  be  made  up  by  the  use  of  a  modified 
cow's  milk.  The  intervals  between  feedings  must  be  just  as  carefully  regulated 
as  in  the  case  of  nursing.  It  is  also  necessary  to  regulate  the  amount  of  food 
given  at  a  time.  A  good  rule  is  at  the  age  of  one  week  to  give  one  ounce  each 
time;  at  four  weeks,  2^  ounces;  at  three  months,  4  ounces;  at  six  months,  6 
ounces;  and  gradually  to  increase  to  8  ounces,  which  is  as  much  food  as  a  child 
should  ever  take  at  a  time  until  weaned.     The  best  results  are  obtained  by 


HYGIENE  AND  MANAGEMENT  OF  THE  NEWLY  BORN  789 

making  certain  modifications  in  the  ingredients  of  cow's  milk  to  make  it  conform 
to  human  milk,  and  by  starting  with  a  very  low  proportion  of  fat  and  proteid, 
gradually  increasing  as  the  child  approaches  eight  or  nine  months.  The  various 
strengths  which  seem  to  give  the  most  satisfactory  results  at  various  ages  are 
thus  tabulated.     The  ingredients  should  be,  in  the  first  months  of  life: 

Fat.  Sugar.  Pkoteio. 

First  week    2.00  5  •  00  0.50 

Second       "      3  -oo  6 .00  o  -75 

First  month 4.00  ,       7.00  i  .  00 

Second    "        4. 00  7. 00  i-5o 

Fourth    "        4.00  7.00  2.00 

Sixth       "        4 .  00  7 .  00  2.50 

Eighth     "        4.00  7.00  2.75 

A  properly  constituted  artificial  food  must  contain  only  substances  normally 
found  in  milk;  it  must  be  alkaline  and  sterile,*  easily  obtained,  and  its  prepara- 
tion not  too  complicated.  It  must  as  nearly  as  possible  be  of  the  composition 
of  human  milk  and  susceptible  of  modification  to  suit  individual  cases.  Cow's 
milk  is  the  most  easily  obtainable  basis  for  modification.  According  to  Meigs, 
the  comparative  average  composition  of  human  and  cow's  milk  is: 

Human  Milk.  Cow's  Milk. 

Water, 87.16  87.10 

Fat 4.28  4.20 

Casein, 1.04  3-25 

Sugar,    7.40  5  ■  00 

Salts o.io  0.52 

Human  milk  is  also  alkaline  and  practically  sterile,  while  cow's  milk  as  it  reaches 
the  consumer  is  usually  slightly  acid  and  always  contains  bacteria.  Other 
analyses  give  somewhat  different  results,  but  these  may  be  taken  as  an  average. 
Human  milk  differs  in  two  important  respects — it  contains  more  sugar  and 
markedly  less  proteid.  The  proteids  of  human  milk  are  casein  and  lactalbumin, 
both  not  in  solution  but  suspension,  and  capable  of  making  a  finely  divided 
curd  more  readily  digestible  than  that  of  cow's  milk.  Further,  the  proteid 
matter  is  of  a  different  character.  Fats  are  about  the  same.  In  some  respects  it 
is  easy  to  make  cow's  milk  conform  to  the  standard.  A  sufficient  amount  of  milk- 
sugar  added  makes  this  ingredient  satisfactory,  and  the  acidity  can  be  corrected 
by  the  addition  of  lime-water.  Brush  and  Jacobi  maintain  that  cane-sugar  is  the 
ideal  addition.  Milk-sugar  is  rapidly  changed  into  lactic  acid.  Sometimes  it  is 
borne  well,  at  others  not,  because  of  the  excess  of  lactic  acid,  which  interferes  with 
digestion.  The  presence  of  harmful  bacteria  must  be  prevented  by  care  and 
cleanliness  and  their  action  may  be  overcome  by  sterilization.  The  regulation  of 
fats  and  proteids  is  not  so  easy.  A  simple  way  is  to  dilute  with  water  till  the  pro- 
teid is  properly  reduced  and  then  add  cream.  When  a  fair  trial  has  been  given 
water  as  a  diluent  and  vomiting  of  tough  curds  or  their  presence  in  the  stools 
persists,  barley  or  oatmeal  water  should  be  used  to  "split"  the  curds.  Diluting 
milk  with  water  does  not  prevent  the  formation  of  tough  curds,  but  diluting 

*  Concerning  the  advisability  of  sterilization,  it  may  be  well  to  mention  that  children 
do  not  thrive  well  upon  milk  which  has  been  subjected  to  a  temperature  of  212°  F.  for 
an  hour  and  a  half.  The  casein  is  made  more  firm  and  certain  changes  occur  in  the  fat 
which  tend  to  constipation.  In  the  summer,  when  diarrheal  diseases  are  prevalent,  it 
may  be  of  advantage  to  resort  to  sterilization  when  clean,  fresh  milk  cannot  be  procured. 
Human  milk  obtained  from  73  breasts  of  64  nursing  women,  examined  by  Honigman  with 
all  aseptic  precautions,  contained  Staphylococcus  aureus  or  albus  in  all  but  four  cases, 
the  number  varying  from  i  to  9000  in  a  cubic  millimeter  which  seems  to  confirm  the 
belief  that  micro-organisms  are  not  necessarily  prejudicial  to  health. 


790  THE  PHYSIOLOGY  OF   THE  NEWLY   BORN. 

with  gruels  does  prevent  the  hardening  of  the  curds,  as  is  proved  experi- 
mentally and  clinically.  Barley  water  is  used  to  prevent  the  formation  of  large 
curds  by  mechanical  separation  of  the  milk  globules,  but  this  is  not  always 
a  good  plan,  because  before  the  third  month  of  life  starch  digestion  practically 
does  not  exist  on  account  of  the  lack  of  development  of  the  pancreas.  Whatever 
modified  milk  is  used  may  be  sterilized  or  pasteurized,  if  necessary,  by  keeping  it 
at  a  temperature  of  157°  to  168°  F.  for  twenty  minutes.  When  boiled,  the  mixture 
is  apt  to  cause  constipation.  The  preparation  of  a  modified  milk  can  be  under- 
taken without  great  trouble  at  home,  but  in  the  larger  cities  the  matter  may 
be  left  to  certain  laboratories,  which  may  be  depended  upon  to  furnish  an 
accurately  modified  food  according  to  directions.  The  cost  is  considerable,  how- 
ever, and  among  the  poor  the  plan  is  not  feasible.  In  this  case  home  modi- 
fication is  necessary.  The  principle  on  which  milk  is  modified  depends  on  the 
separation  of  the  fatty  portions  in  the  cream,  by  standing  or  by  centrifugal- 
ization;  by  these  methods  the  cream  and  fats  are  separated  to  one  part  of  the 
mass  while  the  proteids  and  milk-sugar  remain  equally  distributed  throughout. 
By  regulating  the  time  of  standing  and  selecting  certain  portions  of  the  milk 
mass  it  is  not  difficult  to  select  a  specimen  which  contains  any  desired  strength 
of  cream.     For  example,  a  specimen  standing  six  hours  gives: 

Upper  i, fat,   12.0   %;  sugar,  4-4%;  proteids,  3.78%. 

Upper  i "     10.0%;        "       4.5%;  "  3-85%- 

Lower  i, "        0.25%;        "        4-5%;  "  3-&5%- 

Longer  standing  increases  the  percentage  of  fats  in  the  upper  fifth. 

In  preparing  modified  milk  it  is  necessary  to  work  on  a  percentage  basis  entirely  if 
good  results  are  desired.  Baner  *  has  given  a  simple  and  on  the  whole  satisfactory  method 
of  calculating  the  composition  for  any  desired  modification  of  milk  for  infants'  use. 

Q  =  the  quantity  in  ounces  for  twenty-four  hours.  F  =  the  desired  percentage  of  fat. 
S  =  the  desired  percentage  of  sugar.  P  =  the  desired  percentage  of  proteids. 
A  =  the  desired  percentage  of  alkalinity.  C  =  cream;  M  =  milk;  L.W.  =  lime- 
water. 

Cream, t^—. X  (F  —  P). 

Percentage  of  fat  in  cream  —  4 

Milk,    QXI-c. 

4 

Lime-water,    —  X  Q. 

100 

Water q  _  (C  +  m  +  L.W.). 

Dry  milk-sugar,    (s  -  P)  x  Q_ 

100 

Example:  If  40  ounces  of  a  mixture  containing  4  per  cent,  fat,  7  per  cent,  sugar,  and 
2  per  cent,  proteids  is  required,  proceed  as  follows:  Cream,  ,2  (quantity^f  creain  used)  gives 
6f  ounces.  Milk,  lOO  minus  6f  equals  13^  ounces.  Milk  sugar,  IfL^li  equals  2  oz.  Lime- 
water  q.  s.  to  make  alkaline;  plain  water  up  to  40  ounces.  Mix  and  divide  into  as  many 
bottles  as  desired. 

From  this  it  is  a  simple  matter  to  prepare  the  food,  though  it  will  from  time  to  time 
be  necessary  to  vary  the  proportions  of  some  ingredients.  The  usual  percentage  of  lime- 
water  is  five,  but  it  is  sometimes  necessary  to  use 'ten  or  fifteen. 

Winters  t  gives  the  formulas  on  page  857  for  the  home  modification  of  milk. 
I  give  these  formulas  in  full  because  they  are  the  simplest  and  most  explicit 
with  which  I  am  acquainted.  A  somewhat  more  gradual  strengthening  of 
the  food  during  the  summer  months  should  be  used  than  is  indicated  in  these 
formulae.     As  a  rule,  an  infant  of  three  or  four  months  will  not  digest  more 

*  "  N.  Y.  Med.  Jour.,"  Mar.  20,   1898. 

t  "The  Feeding  of  Infants,"  Button  &  Co.,  New  York,  1901. 


HYGIENE  AND.  MANAGEMENT  OF  THE  NEWLY  BORN. 


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792 


THE  PHYSIOLOGY  OF   THE  NEWLY  BORN. 


n^umber  of 
Feedings. 

Intervals 

lO 

2     hours 

lO 

2             " 

10 

2                 " 

lO 

2               " 

10 

2                " 

8 

2§             " 

7 
6 

3 

3h        " 

than  I  per  cent,  of  proteid  during  the  hot  weather.  During  this  time  also 
many  of  the  digestive  disturbances  may  be  averted  by  increasing  the  proportion 
of  Hme-water  to  one-fourth  of  the  total  quantity  of  the  mixture.  The  prepared 
mixture  is  placed  in  as  many  bottles  as  there  are  feedings  for  the  twenty-four 
hours,  each  bottle  containing  the  amount  of  one  feeding;  the  bottles  are  then 
stopped  with  sterile  absorbent  cotton,  placed  in  a  refrigerator,  and  kept 
at  a  temperature  of  45°  to  50°  F.  until  needed.  The  two  unerring  guides  to 
the  quantity  of  each  feeding  are  the  capacity  of  the  infant  stomach  and  the 
amount  of  milk  secreted  by  the  breasts  of  a  healthy  nursing  woman.  The 
following  table,  also  from  Winters,  shows  the  proper  quantity,  number  of 
feedings,  and  intervals  for  artificial  feeding  up  to  nine  months: 

TABULAR  GUIDE  FOR  ARTIFICIAL  FEEDING. 

Age.  Quantity. 

ist,  2d,  and  3d  days, ^  ounce 

4th,  5th,  6th,  and  7th  days,  .  .  .  i 

2d  week, i^  ounces. 

3d  week 2 

4th,  5th,  and  6th  weeks, 2^        " 

■7th,  8th,  and  gth  weeks, 3 

3d  and  4th  months 3  to  4  " 

5th  to  9th  months, 5  to  6  " 

For  young  infants,  milk  should  not  be  added  to  cream.  Milk  and  cream  do 
not  unite.  If  shaken  together,  and  then  allowed  to  stand  for  a  short  time,  separa- 
tion is  complete.  The  same  occurs  in  the  stomach.  The  stomach  has  practically 
to  cope  with  whole  milk.     Many  failures  are  due  to  this  prevalent  error. 

The  following  percentages  and  relative  proportions  of  fat  and  proteid  must 
be  adhered  to  for  successful  feeding  (Winters) : 

Fat.  Proteid. 

First  three  days, 2.00  0.25  per  cent. 

Succeeding  days — first  week, 2.50      _  0.33  " 

Second  week, 3-oo  0.50  " 

Third  week, 3.50  0.75 

Fourth  to  eighth  weeks, 4.00  i.oo 

Ninth  to  twelfth  weeks, 4.00  1.25 

Fourth  month, 4.00  1.50         " 

Fifth  and  sixth  months, 4.00  1.75 

Seventh,  eighth,  and  ninth  months 4.00  2.00 

Tenth  and  eleventh  months 4.00  2.50         " 

Twelfth  month, 4.00  3.00         " 

In  summer  the  strengthening  must  be  more  gradual,  as  follows  (Winters) : 

Fat.  Proteid. 

First   week, 2.00  0.25  per  cent. 

Second  week, 2.50  0.33 

Third  and  fourth  weeks, 3.00  0.50 

Fifth  and  sixth  weeks, 3.50  0.75 

Seventh  week  to  end  of  third  month, 4.00  i.oo 

Fourth   month, 4.00  1.25 

Fifth  and  sixth  months, 4.00  1.50 

Seventh   month, 4.00  1.75 

Eighth  and  ninth  months, 4.00  2.00 

General  Directions. — A  certain  amount  of  systematic  preparation  and  a 
few  articles  in  the  way  of  apparatus  are  necessary  for  home  modification  and  for 
the  use  of  the  modified  milk  after  it  is  prepared.  These  are:  two  or  three  glass 
jars  to  set  the  milk  in,  fruit-jars  will  do,  a  glass  siphon,  a  dairy  thermometer, 
a  graduated  measure  up  to  8  ounces,  and  a  number  of  4-ounce  and  8-ounce 


HYGIENE  AND-  MANAGEMENT  OF  THE  NEWLY  BORN.         793 

bottles  for  feeding.  A  good  supply  of  rubber  nipples  and  plenty  of  sterilized 
cotton  are  necessary.  A  good-sized  vessel  for  sterilization  is  also  needed.  All 
these  articles  are  to  be  used  sterile,  and  those  which  can  stand  it  are  subjected 
to  boiling  in  a  soda  solution  at  frequent  intervals.  The  same  feeding-bottle  should 
not  be  used  at  consecutive  feedings  and  between  times  should  lie  in  a  soda  solu- 
tion. When  the  milk  is  received,  it  is  allowed  to  stand  in  the  sterile  jars  in  a 
cool  place  as  long  as  desired.  The  lower  part  may  then  be  siphoned  ofE  and 
mixed  in  a  sterile  vessel  with  cream,  lime-water,  sterile  water,  and  milk-sugar  in 


Fig.    994. — A    Good     Type    of     Rubber 
Nipple. 


Fig.  995. 


-A    Good    Type    of    Feeding- 
bottle. 


the  necessary  proportions.  The  formulae  which  have  been  given  may  be  used. 
When  sterilization  is  necessary,  the  modified  milk  may  be  placed  in  the  feeding- 
bottles,  the  mouths  of  which  are  to  be  plugged  with  sterile  cotton,  and  placed 
in  a  wire  rack  in  the  sterilizing  dish  and  lowered  into  the  water,  the  temperature 
of  which  is  then  slowly  raised  to  167°  F.  and  kept  there  for  twenty  minutes. 
After  this  the  bottles  are  to  be  kept  cool  till  needed,  when  they  are  to  be  warmed 
in  water  to  between  99°  and  101°  F.,  the  proper  temperature  for  infant  food. 


Fig.  996. — Nipple  Sterilizer. 


Not  more  than  a  day's  supply  of  food  should  be  prepared  at  a  time.  A  complete 
outfit  for  the  preparation  of  modified  milk  can  be  bought,  but  it  is  no  more 
serviceable  than  are  the  articles  mentioned.  Whatever  preparation  is  used,  the 
greatest  care  as  to  cleanliness  must  be  observed  if  good  results  are  to  be  ob- 
tained. After  each  nursing,  the  bottle  is  rinsed  in  cold  water  which  removes 
the  particles  of  milk  without  coagulating  them  and  then  scalded;  the  nipple 
should  be  washed  in  cold  water  and  both  nipple  and  bottle  kept  in  a  soda 
solution  to  prevent  acid  fermentation.     The  short  nipple  only  should  be  used,  as 


794 


THE  PHYSIOLOGY  OF   THE  NEWLY   BORN. 


it  is  the  only  one  which  can  be  properly  cleansed.  While  the  child  is  feeding  the 
bottle  should  be  encased  in  a  knitted  bag  to  maintain  the  temperature  as  long  as 
possible.  The  amount  usually  required  at  one  nursing  by  a  new-bom  child  for  the 
first  week  is  one  ounce,  gradually  increased  till  the  sixth  week,  when  it  receives 
two  and  a  half  ounces,  but  the  amount  varies  with  the  size  of  the  child.  The 
bottle  should  be  held  so  that  the  child  can  suckle  advantageously;  that  is,  so 
that  its  mouth  is  directly  opposite  the  summit  of  the  nipple.  Certain  symptoms 
may  point  to  the  necessity  of  modifying  the  composition  of  the  child's  food; 
e.  g.,  if  it  regurgitates  its  food  unchanged,  it  is  getting  too  much,  or  the  amount 
.of  fluid  is  too  large;  if  it  takes  its  food  eagerly  but  seems  continually  hungry 
and  does  not  gain  in  weight,  the  proportion  of  solids  may  be  increased,  which 
is  accomplished  by  diminishing  the  water. 


Fig.  997. — Bottle-brush  for  Cleansing  Feeding-bottles. 

4.  Patented  or  Proprietary  Foods. — There  is  one  truth  which  by  this 
time  should  be  taken  as  an  axiom — namely,  that  mother's  milk  is  the  most 
appropriate  food  to  be  taken  by  the  infant  in  all  stages  of  development  and 
no  patented  infant  food  can  even  approximate  it  in  value.  The  majority 
of  such  foods  now  on  the  market  are  either. farinaceous,  made  from  cereals 
and  consisting  largely  of  unconverted  starch,  or  malted  foods,  also  made 
from  cereals  but  having  the  starch  transformed  into  soluble  maltose  and 
dextrin.  They  vary  in  composition  and  strength,  but  as  a  class  contain  an 
excess  of  carbohydrates,  little  if  any  fat,  and  proteids  which  do  not  resemble 
those  in  mother's  milk.  Chittenden  *  analyzed  certain  proprietary  foods 
according  to  directions  for  infants  of  six  months,  with  the  following  results: 


Imperial  granum, i  •  54 

Nestl6's  food, 0.36 

Malted  milk 0.68 


Mellin's  food, 2 


Peptogenic  miilk  powder,  4.38 
Condensed  milk.j i  .70 


Sugar. 

Proteid. 

Starch. 

2.71  milk 

2-15 

I  .22 

0.84      " 

0.81 

1.99 

2.57  cane 

1 .  1 8  milk 

1-15 

3.28  maltose 

0.92  dextrin 

3.25  milk 

2  .62 

2.20  maltose 

0.53  dextrin 

7.26  milk 

2  .09 

6.00  cane 

I  .50 

2.26  milk 

Reaction  alkaline. 


INFANT'S  WEIGHT. 


First  week 7  pounds 

Second  week 7  to    8 

Third  week 8  to    9 

Fourth  to  eighth  week.  ...  9  to  10 
Ninth  to  twelfth  week  ...  10  to  12 
Fourth  month 12  to  14 


Fifth  to  sixth  month 14  to  16  pounds 

Seventh,  eighth,  and  ninth 

month 16  to  18       " 

Tenth  to  eleventh  month.  18  to  19       " 
Twelfth  month 19  to  20       " 


Open  Air. — A  baby  can  be  taken  into  the  open  air  when  a  month  old  ih  mild 
weather,  and  at  about  two  months  in  winter.      In  southern  climates  it  can  of 

*  "  N.  Y.   Med.  Jour.,"  July   18,    1896. 

t  The  percentages  of  condensed  milk  are  those  found  in  the  Milkmaid  brand,  diluted 
with  seven  parts  water. 


HYGIENE  AND  MANAGEMENT  OF  THE  NEWLY  BORN,         795 

course  go  out  much  earlier  than  in  northern  ones.  Under  proper  conditions  the 
more  open-air  life  a  baby  can  have,  the  better.  As  for  exercise,  it  should  be 
allowed  to  kick  and  roll  about  in  its  crib  unhampered  by  long,  clogging  skirts; 
and  to  creep  if  it  wishes,  if  there  are  no  draughts  near  the  floor.  Walking 
belongs  to  a  later  period,  from  about  the  thirteenth  month. 

Sleep. — A  very  young  infant  will  sleep  about  twenty-one  hours  of  the  twenty- 
four,  and  should  be  allowed  to  sleep  and  not  be  roused  to  be  displayed  to  friends. 
It  should  never  sleep  in  bed  with  the  mother  from  danger  of  being  overlaid  and 
also  because  it  is  apt  to  be  covered  with  the  bedclothes  and  the  fresh  air  kept 
from  it.  It  should  have  a  crib,  not  a  rocking  cradle,  near  the  mother's  bed,  and 
should  be  laid  there  to  sleep  without  previous  handling  or  carrying  about. 
Babies  greatly  prefer  the  delicate  attentions  of  rocking  and  carrying,  and  are 
clever  enough  to  insist  upon  having  it  if  they  have  ever  experienced  it,  where- 
fore it  is  for  the  peace  of  all  concerned,  as  well  as  better  for  the  baby's  nervous 
system,  not  to  accustom  it  to  the  luxury.  Other  habits  may  also  be  formed 
at  a  far  earlier  age  than  is  usually  supposed;  I  refer  to  the  evacuation  of  the 
bladder  and  bowels. 

Bladder  and  Bowels.— It  is  difficult  to  regulate  the  passing  of  water,  but 
some  nurses  are  successful  in  securing  a  certain  amount  of  regularity  by  placing 
the  babies  upon  a  vessel  soon  after  feeding.  The  bowels  can  almost  invariably  be 
trained  to  regularity  by  trying  to  secure  a  movement  at  the  same  hour  every  da  v. 
There  will  be  as  many  as  four  a  day  for  the  first  week,  gradually  diminishing  till 
there  are  usually  two  a  day  after  the  sixth  month.  Sometimes  there  is  only 
one,  but  provided  that  is  abundant,  soft,  and  yellow,  not  lumpy,  it  need  cause 
no  anxiety.  Constipation  is  to  be  avoided  as  it  is  the  cause  of  serious  troubles 
and  of  future  bad  habits.  Unceasing  care  must  be  exercised  to  secure  a  good 
movement  at  the  same  hour  every  day,  and  should  the  child  show  "  a  constipated 
habit,"  or  have  hard,  painful  stools,  the  condition  of  the  food  must  be  investi- 
gated. Some  infants  are  constipated  while  nursing  but  become  perfectly 
regular  when  put  on  solid  diet.  Constipation  in  the  mother  will  have  a  great 
effect  on  the  infant's  bowels,  and  she  cannot  be  too  careful  to  keep  herself 
regular  and  avoid  sweets,  starchy  foods,  cakes,  pastries,  and  acids.  In  a  bottle- 
fed  child  the  milk  is  found  frequently  to  be  deficient  in  fats.  Cream  and  water 
will  then  have  to  be  added.  As  far  as  possible  the  use  of  drugs  should  be  avoided 
and  the  desired  end  attained  by  a  healthful  mode  of  life  for  both  mother  and 
child,  plenty  of  fresh  air,  exercise,  a  rational  diet,  loose  clothing,  quiet,  calm- 
ness, and  regular  habits.  Exercise  may  be  given  in  the  passive  form  to  an 
infant  by  gently  rubbing  its  abdomen  with  a  circular  motion.  Diarrhea  is  more 
often  due  to  overnursing  and  overfeeding  and  to  drinking  too  little  w^ater  than  to 
other  causes.  The  habit  of  putting  the  child  to  the  breast  every  time  it  cries 
defeats  its  own  end,  for  it  is  the  best  way  to  sow  the  seeds  of  colic,  vomiting, 
diarrhea,  and  discomfort. 

The  Nursery. — When  it  is  possible,  let  the  nursery  for  the  baby  be  a  sunny 
room  in  which  there  is  no  plumbing  and  which  can  be  well  ventilated  and  easily 
heated.  A  board  eight  inches  wide  slipped  under  the  whole  length  of  the  lower 
sash  will  allow  of  the  entrance  of  air  without  draught,  and  a  register,  an  open 
fire,  or  a  stove  with  a  pan  of  water  always  on  top,  should  keep  the  temperature 
at  about  70°  or  preferably  65°  F.  The  temperature  should  not  vary  much  from 
this  during  the  night  and  the  fresh  air  should  not  be  excluded.  Whatever  the 
prejudice  against  night  air,  it  is  better  than  carbonic  acid  gas  laden  with  im- 
purities from  the  lungs,  and  such  will  be  the  air  of  a  closed  room  in  which  sleep 
a  child  and  a  nurse.     Cleanliness,  simplicity,  cheerfulness,  should  be  the  guiding 


796  THE  PHYSIOLOGY  OF   THE  NEWLY  BORN. 

maxims  in  arranging  a  nursery.  The  fewer  curtains,  hangings,  and  carpets,  the 
better,  as  they  lodge  bacteria.  No  soiled  napkins  should  be  allowed  to  stay  in 
the  room  and  vessels  should  be  removed  and  cleaned  as  soon  as  used. 

Environment. — Even  in  infancy  it  is  well  to  preserve  a  calm  environment 
for  the  baby.  Noise,  excitable  actions  and  tones,  and  much  prancing  and 
dancing  for  the  baby's  entertainment  should  be  avoided.  Children  suffer  from 
too  much  attention  in  the  line  of  amusement,  and  a  little  wholesome  neglect  in 
this  respect  will  not  only  teach  them  to  amuse  themselves,  but  will  induce 
calmer  nerves  and  subsequent  better  health. 

Weaning. — Weaning  should  occur  between  the  ninth  and  fourteenth  months, 
but  some  conditions  may  make  it  desirable  earlier.  It  is  better  to  have  it  a 
gradual  than  a  sudden  process,  substituting  a  little  bread  and  milk,  hominy,  or 
other  cereal  for  one  of  the  regular  feedings. 

Prepuce  and  Hood  of  Clitoris. — i.  In  male  infants,  beginning  on  the  sixth 
or  seventh  day  after  birth,  the  nurse  should  be  instructed  to  retract  the  prepuce 
daily,  drawing  it  back  a  little  every  day  until  all  adhesions  are  broken  up, 
and  the  glans,  as  far  as  the  corona,  is  exposed.  It  usually  takes  two  or  three 
daily  attempts  to  expose  the  glans  completely.  Daily  retraction  should  there- 
after be  practised  by  the  nurse  and  all  smegma  removed  with  a  saline,  boric 
acid  or  very  weak  soap  solution  and  clean  absorbent  cotton.  To  prevent  the 
readhesion  of  the  raw  surfaces,  the  free  application  of  sterile  vaseline  between  the 
prepuce  and  glans  I  have  usually  found  sufficient.  Occasionally  sterile  gauze 
or  cotton,  placed  just  back  of  the  corona,  will  be  demanded  for  this  purpose. 
The  mother  or  child's  nurse  should  subsequently  be  instructed  to  repeat  the 
cleansing  daily  during  infancy,  and  until  the  boy  can  be  taught  to  attend  to 
the  matter  himself. 

Adhesions  between  the  prepuce  and  glans  penis  are  quite  common,  and 
are  often  causative  factors  of  many  reflex  nervous  affections  and  even  con- 
vulsions. 

In  both  private  and  hospital  practice  I  insist  that  firm  adhesions  shall  be 
promptly  reported  to  me.  In  one  of  my  services  at  the  New  York  Maternity 
two  cases  of  persistent  infantile  convulsions  were  promptly  cured  by  circum- 
cision. The  above  described  "stripping"  of  the  glans  penis  will  in  the  newly 
bom  usually  be  found  a  simple  procedure,  and  it  is  much  preferable  that  it 
be  done  in  infancy  by  the  nurse  or  physician,  than  several  years  later  by  the 
boy  of  six  or  eight. 

2.  In  my  experience  the  nymphae  in  female  infants  are  rarely  so  firmly 
adherent  to  each  other  or  to  the  labia  majora  as  in  the  male  is  the  prepuce  to 
the  glans.  This  statement  is  based  upon  several  thousand  observations.  The 
hood  of  the  clitoris  can  usually  be  readily  drawn  back,  and  the  proper  cleansing 
secured,  but  this  is  not  so  necessary  as  in  the  case  of  the  prepuce. 


PART    NINE. 
The  Pathology  of  the  Newly  Born^ 


I.  PATHOLOGY  DUE  TO  INTERRUPTED  PREGNANCY.     PREMATURITY. 

(Page  800.) 

II.  AFFECTIONS  OF  ANTENATAL  ORIGIN  WHICH  EXTEND  INTO  EXTRA- 
UTERINE LIFE.  (Page  807.)  1.  Malformations  and  Monstrosities.  2. 
Acute  Infectious  Diseases.  3.  Chronic  Infectious  Diseases.  4.  General 
Conditions.     5.  Infantile  Syphilis. 

III.  AFFECTIONS  WHICH  ORIGINATE  INTRA  PARTUM.     (Page812.)     1.  As- 

phyxia Neonatorum.     2.  Birth  Traumatisms.     3.  Aspiration   Pneumonia. 

4.  Contagious  Diseases  Contracted  from  the  Mother.  (1)  Ophthalmia 
Neonatorum.     (2)  Gonorrheal  Stomatitis. 

IV.  DISEASES    INCIDENT    TO    CHANGE   OF    ENVIRONMENT.     (Page  837.) 

1.  Primary  Asphyxia  of  the  Newly  Born.  2.  Atelectasis  Neonatorum.  3. 
Failure  of  Circulation.  4.  (Edema  Neonatorum.  5.  Failure  of  Digestion 
and  Assimilation.     Inanition.     6.  Inanition  Fever. 

V.  DISEASES  DUE  TO  BACTERIA  AND  FUNGI.  (Page  840.)  1.  Umbilical 
Sepsis.  2.  Septic  Coryza.  3.  Septic  Pneumonia.  4.  Gastro-intestinal  Sep- 
sis. (1)  Ulcerative  Stomatitis.  (2)  Gangrenous  Stomatitis.  Noma.  (3) 
Parotitis.  (4)  Retropharyngeal  Abscess.  (5)  Gastro-enteritis.  5.  Cutaneous 
Sepsis.  (I)  Dermatitis  Exfoliativa  (Ritter's  Disease).  (2)  Pemphigus  Acu- 
tus  Neonatorum.  Septic  Pemphigus.  (3)  Impetigo  Contagiosa  Neonatorum. 
Periumbilical  Pemphigus.  (4)  Ecthyma  Neonatorum.  (5)  Multiple  Abscess. 
(6)  Erysipelas.     6.  Tetanus.     7.  Aphthae.     8.  Thrush. 

VI.  DISEASES    OF    UNKNOWN   NATURE.     (Page   847.)      1.  Omphalorrhagia. 

2.  Melena.      3.  Miscellaneous    Hemorrhages.      4.   Sclerema   Neonatorum. 

5.  Buhl's  Disease.     6.  Winckel's  Disease*     7.  Mastitis.     8.  Jaundice. 

VII.  GENERAL  POST-PARTUM  CONDITIONS.  (Page  852.)  1.  Ulceration  of 
the  Hard  Palate.  2.  Sublingual  Cysts.  3,  Vomiting.  4.  Colic.  5.  Diar- 
rhea. 6.  Constipation.  7.  Intestinal  Obstruction.  8.  Pneumonia.  9.  Con- 
vulsions. 10.  Infantile  Cachexia.  II.  Sudden  Death.  12.  Medication  of 
the  Newly  Born. 


General  Considerations. — While  it  is  customary  to  assign  particular  causes 
for  individual  infantile  deaths,  the  fact  must  remain  that  in  the  struggle  for 
existence  many  fetuses  and  newly  born  children  are  simply  unable  to  survive, 
and  that  the  particular  disease  which  terminates  their  existence  is  almost  a 
matter  of  indifference  as  compared  with  the  marked  predisposition  to   early 


Antenatal 
ConditMns. 
'  Congenital Debiliti/ 
Diseases  and 
Malformations 
^Dfo 


Fetal  and 
Maternal 

Dptocia 
Intrapartum 

CoTiditions 

^5fo 


Fig.  998. — Diagram  showing  the  Mor- 
tality OF  THE  Newly  Born  in  New 
York. — {Modified  from  A.  Brother's 
tables.) 


Fig. 


Jepsis  or 
^"-^^ostpartum 

Intermptirm  ofPregmncy^^l^^^^L 
(Prematurity) 
-13% 


999. — Diagram   showing  the  Mor- 
tality OF  THE  Newly  Born. 


Fig. 


-Diagram  showing  the  Mortality  of  Infants  in  the  First  Year  of  Life. 

{Biidin.*) 


death.  Nevertheless,  these  various  conditions  of  the  fetus  and  newly  born 
must  be  carefully  considered,  because  many  of  them  are  not  only  capable  of 
producing  death  independently  of  predisposition,  but  are  doubtless  largely 
preventable.  In  countries  in  which  the  birth-rate  is  falling  off  from  unwilling- 
ness on  the  part  of  wedded  couples  to  procreate,  the  rescue  of  the  fetus  and 

*  "L'Obst^trique,"  September   15,    1901. 
799 


800  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 

newly  born  from  some  of  these  fatalities  assumes  tremendous  importance. 
The  pathology  of  the  newly  born  comprises  phases  set  forth  above  (Figs.  998, 
999,  1000). 


I.    PATHOLOGY   DUE  TO    INTERRUPTION    .OF  PREGNANCY. 

PREMATURITY. 

Introduction. — The  premature  expulsion  of  the  contents  of  the  uterus  is  neces- 
sarily fatal  before  a  certain  period  at  which  the  fetus  becomes  viable,  and  is 
known  as  abortion  and  miscarriage.  On  the  other  hand,  interruption  very 
shortly  before  term  need  not  compromise  the  child's  existence.  Between  these 
limits  the  fate  of  the  infant  is  problematical.  It  is,  of  course,  difficult  to  fix  pre- 
cisely the  age  for  survival  of  the  child.  In  some  statistics  the  mortality  of  these 
premature  children  is  excessive;  in  others  the  death-rate  is  relatively  low. 
Generally  speaking,  "prematurity"  is  an  unscientific  term;  for  death,  whether 
in  titer o  or  after  delivery,  must  have  some  cause,  and  prematurity  is  only  a 
predisposition.  No  distinction  can  be  made  in  practice  between  prematurity 
and  congenital  debility,  and  the  exciting  cause  of  death  should  be  sought  for. 
But  while  the  exact  cause  of  death  should  be  determined  in  each  case,  no  one,  of 
course,  denies  that  true  prematurity  is  a  most  common  and  potent  cause  of  still- 
birth and  infantile  death,  and  that  it  affords  a  predisposition  for  the  action  of  all 
other  pernicious  elements.  The  further  removed  the  labor  from  term,  the  greater 
the  influence  of  the  predisposition  (Figs.  998,  999,  1000). 

Definition. — Prematurity  might  be  defined  as  the  act  or  state  of  being  born 
before  term.  A  very  brief  study  of  modern  obstetrical  teaching  will  convince 
one  that  this  subject  has  never  received  due  consideration.  Premature  children 
are  usually  regarded  as  constituting  a  large  share  of  those  congenitally  weak 
infants  who  require  special  care  at  birth.  One  does  not  find  in  obstetric  writings 
any  sharp  line  of  demarcation  between  weak  premature  and  weak  mature 
infants,  at  least  from  the  practical  point  of  view.  Nevertheless  prematurity 
should  constitute  a  particular  field  in  obstetrics  and  should  receive  adequate 
consideration  from  all  points  of  view. 

Percentajge  of  Premature  Births. — The  actual  percentage  of  premature  children  varies 
within  wide  Umits.  In  the  Rotunda  Hospital,  Dublin,  the  number  of  premature  births  is  but 
1  or  2  per  cent.  On  the  other  hand,  Braun,  of  Vienna,  claims  that  his  proportion  of  pre- 
maturity cases  amounts  to  over  35  per  cent,  of  all  births.  Numerous  observers  report  a  per- 
centage about  half-way  between  these  figures,  and  the  average  of  ten  large  clinics  in  various 
parts  of  the  world  is  about  17.50  percent.,  which  must  therefore  be  accepted  as  final.  In  other 
words,  one  birth  out  of  six,  the  world  over,  is  probably  premature.  The  great  variability  in 
different  clinics  and  in  the  same  clinic  in  different  years  is  as  yet  inexplicable.  The  dis- 
crepancy in  the  death-rate  in  different  clinics  matches  that  of  the  birth-rate.  In  the 
English  vital  statistics  13  per  cent,  of  the  mortality  of  the  first  year  of  life  is  due  to  pre- 
maturity. The  rate  in  the  Paris  Maternity  is  about  20  per  cent.  Rosthorn  reports  a 
death-rate  of  but  i  per  cent.,  Ahlfeld  of  2  per  cent.,  Hofmeier  of  less  than  3  per  cent.  On 
the  other  hand,  Winckel's  figures  are  11.5  per  cent.,  and  the  mortality  in  certain  clinics 
rui's  up  to  30  per  cent.,  while  a  few  go  beyond  this  limit,  and  even  one  as  high  as  50  per 
cent.  Murillo,  of  Santiago,  Chili,  has  kept  records  for  a  number  of  consecutive  years, 
and  his  death-rate  from  prematurity  varies  from  5  to  10  per  cent.  As  far  as  may  be  de- 
termined, the  mortality  of  prematurity  will  average  something  like  20  per  cent.,  the  indi- 
vidual variatiori  and  general  average  being  much  the  same  as  those  of  the  birth-rate. 

Etiology. — Prematurity  is  not  solely  a  matter  of  chronology,  for  the  develop- 
ment of  the  fetus  does  not  necessarily  keep  pace  with  the  calendar.  A  child  may 
be  bom  at  term  and  yet  be  backward  in  development;  and,  conversely,  children 
may  be  bom  before  term  and  yet  be  fully  mature.     Prematurity,  therefore,  is  an 


PATHOLOGY  DUE  TO  INTERRUPTION  OF  PREGNANCY         801 

ambiguous  term  which  may  refer  ahke  to  the  date  of  labor  and  the  state  of  de- 
velopment of  the  child.  Such  ambiguity  should  not  exist,  and  terms  should  be 
introduced  to  distinguish  between  these  two  ideas.  Of  these  two  conceptions  of 
maturity,  the  merely  chronological  phase  should  be  regarded  as  incidental,  while 
the  element  of  the  state  of  development  of  the  fetus  at  birth  should  be  regarded 
as  essential. 

Symptoms. — The  objective  qualities  of  a  premature  child  are  well  known 
and  tolerably  constant.  As  compared  with  a  mature  child,  the  premature 
infant  presents  a  bright  red  color  with  a  small  quantity  of  vernix  caseosa; 
there  is  a  dearth  of  subcutaneous  fat,  so  that  the  skin  hangs  in  folds.  The  child 
is  somnolent,  has  a  weak  cry,  limp  muscles,  and  shallow  breathing.  Sucking 
and  swallowing  are  performed  with  difficulty.  The  eyes  are  closed.  In  regard 
to  relative  dimensions,  the  head  is  larger  in  proportion  to  the  body  than  in 
maturity  and  the  belly  is  more  prominent.  A  still  closer  investigation  of  the 
premature  child  shows  a  number  of  minor  peculiarities.  The  head  is  com- 
pressible, the  sutures  and  fontanelles  being  wide  open,  and  asymmetry  may 
result  from  compression  in  one  portion.  The  ears  lie  fiat  against  the  head. 
The  skin  is  very  delicate,  showing  the  subcutaneous  veins,  and  is  covered 
uniformly  with  lanugo.  The  nails  are  soft  and  do  not  extend  to  the  ends 
of  the  fingers.  From  the  twentieth  to  the  twenty-fourth  week  the  lanugo  and 
vernix  caseosa  first  appear;  the  scalp  hair  has  become  differentiated  In  the 
male  the  scrotum  is  small,  and  as  yet  empty,  while  in  the  female  the  labia 
majora  are  separated  by  the  clitoris.  The  surface  of  the  child  is  bright  red. 
Children  born  at  this  period  can  move  and  breathe.  From  the  twenty-fourth 
to  the  twenty-eighth  week  subcutaneous  fat  begins  to  appear  in  the  region  of 
the  neck  shoulders,  and  breast.  The  nails  are  represented  only  by  firm  folds 
of  integument.  Children  born  during  this  period  are  able  to  cry  softly.  From 
the  twenty-eighth  to  the  thirty-second  week  the  pupillary  membrane  disappears, 
the  intense  red  color  fades  out,  the  subcutaneous  fat  becomes  diffused  over  the 
body,  and  the  nails  are  developed  nearly  as  far  as  the  finger-tips.  Children  born 
during  this  period  are  viable.  From  the  thirty-second  to  the  thirty-sixth  week 
the  child  resembles  a  mature  infant,  the  differences  being  of  degree  only.  Thus, 
there  is  less  subcutaneous  fat  present,  so  that  the  skin  is  somewhat  wrinkled; 
the  cranial  bones  are  more  pliable,  the  nails  are  shorter  and  less  firm,  and  the 
lanugo  is  more  abundant.  The  scrotum  of  a  male  child  born  at  this  period 
exhibits  wrinkles  and  folds.     (Compare  pages  85  and  86.) 

Physiological  Peculiarities. — The  premature  child  has  physiological  as  well 
as  anatomical  peculiarities.  In  heat-making  power  it  is  defective,  doubtless 
because  of  its  imperfect  respiration,  and  the  temperature  constantly  fluctuates 
by  reason  of  the  defective  action  of  the  heat-regulating  mechanism  or  instability 
of  the  respiratory  center.  The  thorax  is  somewhat  inelastic  and  the  lungs  are 
prone  to  atelectasis.  Respiration  is  carried  on  only  by  the  anterior  portion 
of  the  lungs.  The  premature  child  does  not  regain  its  initial  loss  of  weight 
for  a  month.  Naturally  these  infants  are  ill  fitted  to  sustain  the  traumatisms 
of  labor,  where  the  compression  favors  congestion  and  hemorrhage.  I  have 
often  noted  the  frequency  of  ecchymoses  in  breech  deliveries  of  the  premature. 
Interstitial  hemorrhage  into  the  nervous  centers  is  doubtless  favored,  with 
production  of  athetosis  and  cerebral  diplegia.  In  addition  to  the  natural 
inability  to  nurse,  the  contact  of  the  rubber  nipple  or  teaspoon,  as  well  as  the 
operation  of  gavage,  is  a  source  of  dangerous  irritation.  The  premature  child 
is  especially  liable  to  hernia,  both  inguinal  and  umbilical,  because  its  orifices 
are  insufficiently  closed.  The  descent  of  the  testicle  also  favors  inguinal  hernia. 
51 


S02  THE  PATHOLOGY   OF  THE  NEWLY   BORN. 

The  first  attempts  at  respiration  may  provoke  fatal  paroxysms  of  cyanosis. 
While  some  authorities  mention  a  "premature"  quality  of  pulse  and  respiration, 
a  pulse  of  140  and  respiration  of  40  to  60  are  not  incompatible  with  perfect 
health.  Anuria  is  sometimes  seen  in  the  premature.  Determination  of  the  age 
of  the  fetus  by  the  calendar  is  at  best  very  difficult,  for  obvious  reasons.  Prac- 
tical obstetrics  recognizes  no  distinction  in  congenitally  feeble  children  inde- 
pendent of  the  date  of  birth.  It  is  better,  I  believe,  to  do  away  with  the 
element  of  time  in  these  cases  and  to  be  guided  solely  by  the  state  of  develop- 
ment of  the  child.  At  the  same  time,  however,  in  the  matter  of  artificially 
induced  premature  delivery,  we  have  to  rely  largely  upon  the  calendar,  because 
we  have  no  means  by  which  we  may  be  able  to  estimate  the  degree  of  develop- 
ment of  the  child  in  utero.  The  newly  developed  science  of  external  cephalom- 
etry,  as  practised  to-day  in  Paris,  may  possibly  become  effective  in  determining 
the  degree  of  development  through  intrauterine  mensuration  of  the  head. 
(Compare  page  180.)  At  present  the  real  criterion  of  maturity  is  the  develop- 
ment of  the  child  at  birth.  Of  the  various  criteria  proposed,  some  authorities 
prefer  the  temperature;  others,  the  dimensions  and  weight.  Eross,  of  Budapest, 
made  11 50  measurements  in  50  premature  children.  Of  them,  19  had  normal 
temperature,  18  hyperthermia  (due  to  some  febrile  complication),  while  in  the 
remaining  13  the  temperature  was  subnormal.  To  estimate  the  degree  of  pre- 
maturity or  debility  we  must  consider  (i)  age  (development),  (2)  weight,  (3) 
temperature.  Budin  regards  every  newly  bom  infant  with  a  rectal  temperature 
of  not  more  than  90°  F.  (32°  C.)  as  a  candidate  for  the  incubator.  Some  would 
regard  all  children  as  congenitally  feeble  whose  weight  does  not  exceed  4.37 
pounds  (2000  grams);  others  make  the  limit  5^  pounds  (2500  grams).  In 
regard  to  the  causes  of  congenital  debility,  we  find  children  born  at  term  who 
are  nevertheless  premature  in  development  when  the  mother  suffered  during 
gestation  from  anemia,  hyperemesis,  and  cancerous  cachexia.  At  the  same 
time  very  poorly  nourished  women  may  bear  fine  children. 

Prognosis. — The  prognosis  varies  with  the  degree  of  prematurity  and  the 
development  of  the  infant.  A  child  bom  but  a  few  weeks  before  full  term, 
with  a  vigorous  cry,  circulation  well  established,  and  capable  of  taking  nourish- 
ment, will  require  scarcely  more  attention  than  a  full-term  baby,  but,  as  a 
rule,  in  premature  infants  the  problem  of  feeding  and  maintaining  the  animal 
heat  is  not  easy  to  solve.  Premature  infants  or  those  inherently  delicate 
require  the  utmost  care  and  attention.  Only  a  small  proportion  of  children 
bom  before  the  seventh  month  survive,  but  after  the  seventh  month,  the  recog- 
nized period  of  viability,  the  percentage  of  infants  saved  varies  from  50  to 
96.     The  nearer  full  term,  the  greater  the  child's  chances  of  life. 

Treatment. — There  are  three  main  principles  in  the  treatment  of  prema- 
turity: (i)  The  temperature  immediately  surrounding  the  child  should  be  such 
as  is  adapted  to  its  requirements;  (2)  its  nutrition  should  be  maintained  by 
proper  feeding;  (3)  the  amount  of  handling  or  other  disturbance  should  be  re- 
duced to  a  minimum. 

Management  at  Birth. — The  temperature  of  the  lying-in  room  should 
be  carefully  regulated  and  the  child  should  be  handled  with  the  greatest  care 
from  the  moment  of  birth.  The  rule  that  the  cord  should  not  be  ligated  until 
it  has  ceased  pulsating  is  here  obviously  of  special  importance.  Meanwhile  the 
child  should  be  wrapped  in  warm  blankets.  As  soon  as  the  cord  is  ligated 
the  child  should  be  thoroughly  wrapped  in  warm  cotton  batting,  the  face  only 
being  uncovered.  It  should  then  be  wrapped  in  warm  blankets  and  transferred 
to  the  incubator.     If  artificial  respiration  is  necessary,  those  methods  which 


PATHOLOGY  DUE  TO  INTERRUPTION  OF  PREGNANCY.         803 

involve  the  most  rough  handling  and  exposure  to  cold  should  be  avoided  if 
possible.     (See  page  819.) 

Bathing;  Dressing. — Premature  children  should  not  be  bathed,  but  may 
be  cleansed  as  becomes  necessary  with  a  soft  cloth  and  warm  sweet  oil.  The 
action  of  the  skin  may  be  improved  by  anointing  the  body  every  two  or  three 
days  with  the  same  material.  All  handling  not  absolutely  necessary  should 
be  prohibited.  The  child  enveloped  in  warm  cotton  batting  or  in  the  heated 
air  of  the  incubator  needs  no  clothing  except  a  diaper,  and  should  have  none, 
since  even  the  passive  movements  necessary  in  dressing  are  somewhat  of  a 
shock  to  these  feeble  children.  Absorbent  cotton,  which  may  be  used  and 
thrown  away  as  required,  should  be  preferred  to  the  ordinary  diaper.  Chafing 
should  be  carefully  guarded  against. 

Alimentation. — Ordinarily  the  weakened  condition  of  the  infant  precludes 
the  possibility  of  nursing  or  of  taking  the  proper  amount  of  nourishment 
from  a  bottle.  Feeding  with  a  small  medicine-dropper,  at  intervals  of  one 
or  two  hours,  is  advised.  The  amount  given  at  each  feeding  depends  on 
the  capacity  of  the  infant.  One-half  ounce  is  a  proper  amount  to  begin 
with.  In  many  cases,  however,  gavage,  or  forced  feeding, — described  else- 
where,— is  indispensable.  Breast-milk  from  a  woman  having  a  child  between 
two  or  three  weeks  and  several  months  old  is  the  best  form  of  nourishment, 
and  when  given  makes  the  prognosis  decidedly  better.  Equal  parts  of  a 
sugar  solution  should  be  added  to  the  breast-milk.  Cow's  milk  is  employed 
only  when  it  is  impossible  to  obtain  breast-milk,  and  then  in  weak  propor- 
tions. I  have  used  modifications  containing  fat,  0.5  to  i  ;  sugar,  4.0  to  8.0; 
and  proteids,  0.25  to  0.75  with  success.  The  amount  and  frequency  of  such  feed- 
ings are  increased  as  the  infant's  nutrition  warrants.  Plain  sterile  water  should 
be  given  freely ;  it  adds  to  the  body-weight  and  helps  elimination  through  the  skin, 
bowels,  and  kidneys.  These  children  must  be  fed  in  proportion  to  their  weight, 
which  may  not  exceed  4  pounds  (1800  grams).  They  must  be  fed  promptly 
after  birth;  insufficient  nourishment  is  shown  by  cyanosis,  almost  inevitably 
a  fatal  prognostic  symptom.  Budin  sought  to  determine  the  stomach  capacities 
of  these  children  by  autopsies  upon  fetuses  of  different  uterine  ages,  and  quite 
recently  Planchon  *  has  proceeded  with  a  similar  aim  in  a  different  fashion. 
While  Budin  experimented  with  the  cadaveric  stomach,  Planchon's  work  has 
been  done  upon  the  living  subject.  .An  account  was  taken  of  the  quantity  of 
milk  ingested,  whether  from  the  breast  or  by  gavage,  spoon-feeding  or  drinking 
from  a  glass.  It  was  ascertained  that  the  amount  of  milk  increased  with  each 
day,  and  the  heavier  the  child,  the  greater  the  amount  of  milk  taken, 

Gavage. — In  the  treatment  of  premature  and  congenitally  weak  infants, 
it  is  necessary  at  times  to  resort  to  gavage  or  forced  feeding,  by  which  is  meant 
the  introduction  through  a  tube  of  food  into  the  stomach  (Fig.  1002).  A  small 
funnel  of  rubber  or  glass,  two  feet  of  rubber  tubing,  a  No.  7  French  scale  rubber 
catheter,  and  a  small  glass  tube  three  inches  long  to  connect  the  tubing  with  the 
catheter,  are  required — practically  the  same  apparatus  used  in  stomach  wash- 
ing. When  gavage  is  to  be  performed,  the  infant  should  lie  flat  on  its  back 
in  the  arms  of  a  nurse,  its  arms  held  at  the  sides,  and  the  head  steadied 
by  an  assistant.  The  catheter  is  then  quickly  passed  into  the  stomach 
and  the  food  poured  into  the  funnel,  which  is  raised.  As  soon  as  the  funnel 
is  empty  the  catheter  is  withdrawn,  pinching  it  to  prevent  the  escape  of  any 
fluid  into  the  pharynx.  In  very  young  infants  the  jaws  can  readily  be  separated 
by  the  fingers  of  the  operator;  in  older  children  a  mouth-gag  may  be  required. 

*"  L'Obst^trique,"  1901,  vi,  No.  5. 


804 


THE  PATHOLOGY  OF   THE  NEWLY   BORN. 


If  the  food  is  regurgitated,  the  process  should  be  repeated.  After  feeding  the 
child  should  be  kept  as  quiet  as  possible.  The  children  nourished  in  this  manner 
should  be  fed  at  longer  intervals  than  those  suited  to  other  conditions,  the  length 


'  --^x^' 

yf<') 

— -._ 

^^^f 

■      > 


// 


Fig.  iooi. — The  Operation  of  Stomach  Washing  (Lavage).  For  forced  feeding  (gavage) 
the  infant  is  placed  fiat  on  its  back  (Fig.  1002).  The  same  apparatus  is  used  in  both  pro- 
cedures, and  both  operations  are  valuable  in  the  treatment  of  premature  and  congeni- 
tally  weak  infants. 


of  the  interval  being  determined  by  the  requirements  in  each  case.  It  is  a  good 
plan  to  wash  the  stomach  before  the  first  feeding  of  the  day  (Fig.  looi).  Gavage 
is  more  largely  used  in  the  treatment  of  premature  infants  kept  in  incubators, 


PATHOLOGY  DUE  TO  INTERRUPTION  OF  PREGNANCY. 


805 


but  it  is  also  indicated  after  operations  on  the  nose  and  throat  and  about  the 
neck,  and  in  habitual  vomiting.  Food  given  by  a  tube  often  remains  in  the 
stomach  when  other  methods  of  feeding  are  followed  by  vomiting.  In  certain 
serious  conditions,  such  as  pneumonia,  diphtheria,  and  scarlet  fever,  the  life  of 
the  child  may  depend  upon  gavage.  In  cases  in  which  disease  of  the  mouth, 
spasm  of  the  muscles  of  the  jaws,  or  intubation  renders  swallowing  difficult  or 
impossible,  nasal  feeding  is  resorted  to.  A  soft-rubber  catheter  lubricated  with 
vaselin  or  glycerin  is  gently  pushed  into  the 
nostril,  through  the  pharynx  into  the  eso- 
phagus and  stomach,  and  the  feeding  ac- 
complished as  described  above.  Stimulants 
and  other  medicines  may  be  given  by  these 
methods. 

Incubation. — History:  According  to 
Baumm,*  the  first  incubator  was  devised 
by  Denuce,  of  Bordeaux,  in  1857.  Crede's 
apparatus  dates  from  1864,  and  served  as 
a  model  for  many  years.  In  1880  Winckel 
introduced  his  permanent  water-bath  to 
the  profession,  but  it  proved  cumbersome. 
Tarnier's  incubator  dates  from  the   same 


Fig.  1002. 


-The  Operation  of  Forced  Feeding 
OR  Gavage. 


Fig.  1003. — A  Good  Type  of  Incuba- 
tor OR  CouvEusE.      (Lion  Pattern.) 


period.  Quite  recently  numerous  improvements  have  been  added  to  the 
older  incubators  and  new  designs  have  been  introduced.  At  present  the  well- 
known  "Lion  couveuse"  takes  precedence  over  all  others.  It  is  self-regulat- 
ing within  two  degrees  (Fig.  1003).  In  the  absence  of  an  incubator,  or  until 
one  can  be  procured  in  private  practice,  the  application  of  artificial  heat  may 
be  carried  out  by  swaddling  the  infant  in  raw  cotton,  head  and  all,  leaving 
*  "AUgem.  med.  Ztg.,"  April  4,   1900. 


806  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 

only  the  face  exposed,  wrapping  it  about  with  a  blanket  and  tying  it  around 
with  a  roller  bandage.  Hot  bottles  should  be  placed  on  each  side  of  it. 
A  very  convenient  method  is  to  place  the  infant  in  a  baby's  basket  half- full  of 
raw  cotton  in  which  numerous  hot  bottles  have  been  placed.  The  only  other 
covering  is  a  diaper  and  a  shirt.  The  temperature  of  the  room  should  be  com- 
fortably warm,  particularly  when  the  infant  is  stripped  for  a  rubbing  with 
oil.  When  these  means  fail  to  meet  the  indications,  an  incubator  must  be 
employed.*  Action:  When  a  child  is  placed  in  the  incubator,  its  pulse  and 
respiration  are  slightly  accelerated,  returning  to  the  normal  toward  the  sixth 
day,  save  that  the  respiration  still  remains  slightly  increased.  The  peripheral 
temperature  is  increased  to  a  higher  degree  in  the  axilla  than  in  the  rectum. 
Proper  temperature:  It  may  vary  from  86°  to  98.6°  F.  (30°  to  37°  C.)  according  to 
the  circumstances.  Tarnier  thought  the  average  should  be  about  90°  F.  (32°  C), 
Pinard  93°  F.  (34°  C),  while  Colrat  claimed  that  a  higher  temperature  than 
86°  F.  (30°  C.)  was  discomforting  to  the  child.  Bonnaire  obtained  good  results 
at  90°  F.  (32°  C).  This  temperature,  90°  F.,  I  have  found  to  be  satisfactory, 
although  as  high  as  95°  F.  (35°  C.)  is  occasionally  required.  Whatever  the 
initial  temperature,  it  should  gradually  be  diminished,  and  it  should  descend 
to  77°  F.  (25°  C.)  before  the  child  is  withdrawn  from  the  incubator.  Dangers: 
The  incubator  is  not  unanimously  recommended  for  prematurity.  Serious 
objections  are  found  to  its  use.  The  trouble  with  the  premature  child  is 
a  lack  of  thermogenic  power,  rather  than  superradiation.  Hence,  the  incu- 
bator is  essentially  meddlesome  and  possibly  contraindicated.  The  air  of  the 
incubator  necessarily  becomes  foul,  but  this  is  somewhat  offset  by  the  method 
of  construction  of  the  latest  models.  The  sudden  change  of  the  child's  tem- 
perature when  it  is  taken  from  the  incubator  to  be  bathed,  etc.,  has  never 
been  shown  to  be  prejudicial,  despite  the  views  of  theorists.  The  possibility 
of  the  transmission  of  disease  by  the  apparatus  must  receive  the  most  serious 
consideration,  and  constitutes  a  weighty  contraindication  to  its  employment. 
The  danger  here  is  twofold,  for  the  child  may  not  only  contaminate  itself  from 
a  putrefying  cord  or  feces,  but  the  incubator  serves  well  for  the  incubation 
and  maintenance  of  germs  which  may  infect  the  next  child  destined  to  occupy  the 
apparatus.  The  problem  of  ventilation  has  not  yet  been  solved.  Most  modem 
incubators  are  entirely  too  small  for  the  amount  of  air  required  by  the  child. 
There  is  a  serious  danger  in  the  possibility  of  suffocation  in  connection  with 
vomiting,  and  to  avoid  this,  constant  supervision  is  necessary.  In  a  case  of 
Wormser's  a  child  choked  to  death,  milk  coagula  having  been  found  in  the 
bronchi.  The  closed  incubator  made  it  impossible  to  hear  the  warning  cough 
of  the  child,  which  should  have  been  kept  out  of  the  incubator  for  some  time 
after  feeding.  Baumm's  studies  with  the  "Lion  couveuse"  gave  the  following 
results:  At  98.6°  F.  (37°  C.)  200  cubic  inches  (3300  c.c.)  of  air  are  admitted 
every  second,  which  means  that  the  entire  air  of  the  couveuse  is  renewed  every 
minute.  This  amount  is  fully  sufficient  for  all  demands.  A  child  which  has 
been  in  the  incubator  two  hours  shows  in  the  waste  air  a  gain  of  carbonic  acid 
amounting  to  but  0.16  per  thousand,  showing  that  the  purification  of  the  air 
of  the  incubator  has  been  very  complete.  As  to  the  children  suited  for  the 
incubator,  there  is  no  necessary  relationship  between  weight  and  vigor  on  the 
one  hand,  and  production  of  heat  on  the  other.  A  child  which  has  subnormal 
temperature  and  cannot  be  kept  warm  by  packing  should  go  to  the  incubator. 

*  The  Lion  Incubator  may  now  be  rented  in  New  York  city  from  The  Kny-Scheerer 
Co.,  225  Fourth  Avenue,  New  York,  at  a  cost  of  $5.00  for  installation,  $5.00  for  removal,  and 
50  cents  per  day  for  rental. 


ANTENATAL  AFFECTIONS  IN   EXTRAUTERINE  LIFE.         807 

Duration  of  Treatment. — The  child  should  be  fed  till  it  is  able  to  nurse 
without  exhaustion.  Seven  months'  children  will  probably  need  to  be  fed  for 
weeks,  while  those  of  eight  months  may  be  able  to  nurse.  The  duration  of 
the  child's  stay  in  the  incubator  will  vary  with  its  progress  and  development. 
It  may  not  be  necessary  to  keep  it  there  till  full  term.  Attempts  at  discon- 
tinuing the  treatment  should  be  cautious  and  tentative.  The  temperature 
of  the  apparatus  should  be  lowered  gradually.  As  the  child  grows  stronger,  it 
may  be  taught  to  nurse  by  feeding  it  through  a  nipple  shield,  which  should  be 
perfectly  clean.* 


II.   AFFECTIONS   OF  ANTENATAL   ORIGIN   WHICH    EXTEND 
INTO  EXTRAUTERINE  LIFE. 

./.   Malformations  and  Monstrosities.      2.  Acute  Infectious  Diseases,     j.   Chronic  Infectious 
Diseases.     4.  General  Conditions.     5.  Infantile  Syplnlis. 

It  has  already  been  stated  in  the  section  upon  this  subject  that  the  fetus 
may  be  attacked  in  vitero  by  a  number  of  conditions,  many  of  which  render  its  sur- 
vival impossible  (pages  242  and  255).  If  the  pernicious  influences  are  exerted 
during  the  embryonal  period,  certain  malformations  and  monstrosities  arise,  some 
of  which  are  compatible  with  survival.  During  the  fetal  period  pathogenic  influ- 
ences produce  alterations  more  like  those  seen  in  extrauterine  life.  But  aside 
from  definite  diseases,  it  is  probable  that  in  many  toxic  or  cachectic  states 
of  the  mother  the  fetus  undergoes  a  sort  of  arrest  of  development  or  stunting, 
so  that  it  presents  many  of  the  phenomena  of  prematurity.  No  distinction  is 
possible  between  a  condition  which  breaks  out  in  utero  and  one  which  appears 
just  after  delivery.  It  is  certain  that  the  agencies  which  produce  the  disease 
act  in  utero,  and  if  their  action  is  exerted  very  late  in  pregnancy,  or  if  it  super- 
induce labor,  the  manifestations  of  the  disease  will  occur  post  partum.  An 
antenatal  affection  may  run  its  course  before  delivery  takes  place;  or  may  begin 
before  birth  and  complete  its  cycle  post  partum;  or,  finally,  may  be  contracted 
before  labor,  but  manifested  only  afterward. 

I.  Malformations  and  Monstrosities. — The  various  congenital  malforma- 
tions and  monstrosities  have  been  noted  elsewhere  (Part  III).  Of  the  lesser 
monsters,  some  are  compatible  with  survival  (harelip,  exstrophy  of  the  bladder, 
etc.);  some  naturally  incompatible  with  survival  are  amenable  to  treatment 
(imperforate  rectum,  etc.),  while  others,  likewise  incompatible  with  survival, 
are  also  beyond  the  resources  of  treatment;  e.  g.,  imperforate  esophagus.  Of 
the  major  monstrosities,  many  cases  of  teratomelus  are  capable  of  survival 
(phocomelus  [Fig.  353],  etc.),  but  other  single  monsters  can  live  only  when  the 
malformation  is  very  slight,  as  in  the  first  degree  of  cyclopia. 

*  Statistical. — In  1900  Berend  and  Deutsch  ("Arch.  f.  Kinderheilkunde,"  xxviii,  1900) 
addressed  170  letters  of  inquiry  to  the  chiefs  of  maternities  in  Europe  and  America  in 
regard  to  congenital  debility.  They  received  about  thirty-six  replies,  the  most  satisfactory 
of  which  were  from  Wiirzburg,  Prague,  Bologna,  and  Dublin.  The  circular  letter  referred 
to  comprised  eight  queries,  viz.:  (i)  What  percentage  of  new-bom  children  are  premature? 
(2)  What  is  the  mortality  of  the  new-bom?  (3)  Is  the  incubator  used?  (4)  Is  it  dis- 
infected? (5)  What  is  the  average  number  of  days  spent  in  the  incubator?  (6)  Has  the 
incubator  lessened  the  mortality  among  the  premature?  (7)  If  no  incubator  is  used,  what 
replaces  it?  (8)  What  is  the  mode  of  feeding?  In  regard  to  the  use  of  the  incubator 
32  answers  from  clinics  were  received  by  Berend  and  Deutsch.  It  appears  that  but  three 
institutions  use  the  Lion  couveuse;  11  the  Tamier-Auvard  apparatus;  7  the  Crede  apparatus; 
while  in  the  other  11  the  old  custom  of  wrapping  the  children  in  cotton  still  obtains.  In 
regard  to  the  temperature  of  the  incubator,  "it  should  vary  inversely  with  that  of  the  child." 


808 


THE  PATHOLOGY  OF   THE  NEWLY   BORN. 


2.  Acute  Infectious  Diseases. — Children  have  been  born  with  a  full  variolous 
eruption,  or  the  exanthem  may  not  appear  until  several  days  post  partum. 
Such  cases  occur  very  infrequently.  The  child  dies  as  a  rule,  but  recovery 
has  been  recorded.      Both  variola  and  vaccinia  of  the  mother  may  confer  im- 


i, 


Fig. 


1004. 


-Large  Umbilical  Hernia  in  the  Newly  Born  Containing  a  Portion  of 
THE  Intestines,  Liver,  Stomach,  and  Spleen. — {Author's  case.) 


\ 


munity  against  smallpox  on  children  who  have  escaped  actual  infection  in  utero, 
but  such  immunity  is  short-lived.  In  the  recorded  cases  of  measles  the  children 
have  always  been  bom  with  full  rash,  the  disease  apparently  exploding  in  the 
mother  and  fetus  at  the  same  time.     It  is  otherwise  with  scarlatina,  which  in 

some  cases  has  not  broken  out 
in  the  child  until  the  first  day 
postpartum.  In  a  few  cases 
the  newly  bom  have  been 
healthy  at  first,  but  contract- 
ed the  maternal  disease 
secondarily,  probably  from 
the  breast-milk.  No  case  of 
intrauterine  transmission  of 
diphtheria  is  known,  but  the 
newly  bom  have  been  infected 
through  other  channels  when 
the  mother  was  suffering  from 
the  disease.  The  children 
bom  of  women  with  typhoid 
jever  exhibit  a  high  degree  of 
congenital  debility  and  often 
succumb.  The  same  is  true 
of  the  children  of  malarious 
mothers  who  also  show  at  times  positive  evidences  of  the  disease  itself  (congeni- 
tally  enlarged  spleen,  etc.) .  Children  may,  of  course,  be  bitten  soon  after  delivery 
by  infected  mosquitos,  and,  generally  speaking,  malaria  may  from  one  cause  or 


Fig.  1005. — Congenital  Bilateral  Fissure  of  the 
Hard  Palate,  Cleft  Soft  Palate,  and  Slight 
Degree  of  Hare-lip. — {Author's  case.) 


ANTENATAL  AFFECTIONS  IN  EXTRAUTERINE   LIFE.        809 

another  be  encountered  in  the  newly  born  of  highly  malarious  districts.  It 
presents  but  little  difference  from  the  type  found  in  older  individuals.  Children 
have  been  bom  with  the  evidences  of  influenza.  In  regard  to  sepsis  of  the  newly 
born  which  has  been  contracted  in  utero,  children  have  been  born  with  a  septic 
form  of  pneumonia,  and  it  is  supposed  that  some  of  them  survive  this  experience, 
although  this  is  only  an  inference.  Children  have  been  born  of  rheumatic  mothers 
with  all  the  phenomena  of  acute  rheumatism.  For  further  information  upon  this 
and  analogous  affections,  see  Antenatal  Diseases,  page  255. 

3.  Chronic  Infectious  Diseases, — In  a  very  few  cases  of  actual  congenital 
tuberculosis  the  children  were  born  tuberculous,  succumbing  to  the  disease 
within  a  short  time.  The  offspring  of  tuberculous  mothers,  while  almost  invari- 
ably free  from  tuberculosis,  exhibit  a  high  degree  of  congenital  debility  and 
perish  readily  from  secondary  mortality.  It  is  not  unlikely  that  some  of  the 
children  of  the  tuberculous  are  born  with  the  virul-ent  bacilli  in  their  tissues  and 
are  doomed  to  be  infected  perhaps  forthwith,  perhaps  not  until  adolescence.  If 
fetal  syphilis  does  not  prove  fatal  in  utero, — a  rare  exception  to  the  general 
rule, — the  child,  in  addition  to  the  visceral  lesions  already  described  (page 
259),  presents  certain  phenomena  which  are  due  evidently  to  failure  in  adjusting 
itself  to  the  new  surroundings.  Such  infants  can  survive  but  a  short  time, 
and  their  condition  is  known  as  syphilis  neonatorum,  to  distinguish  it  from 
syphilis  contracted  in  utero,  which  does  not  manifest  itself  until  a  month  or 
thereabouts  after  delivery.  This  latter  type,  being  extremely  common,  is  the 
familiar  infantile  or  congenital  syphilis.  A  peculiarity  of  syphilis  of  the  newly 
born  is  the  general  tendency  to  hemorrhage.  The  characteristic  lesions  of  this 
phase  of  syphilis  comprise  bullae  which  may  exceptionally  begin  in  utero,  but 
as  a  rule  tend  to  appear  soon  after  birth.  Their  seat  of  predilection  is  the 
palms  and  soles,  and  they  should  not  be  confounded  with  septic  pemphigus  of 
the  newly  bom  (Fig.  1006).  These  bullae  have  a  hemorrhagic  tendency,  and  the 
same  disposition  to  bleed  found  in  most  of  the  tissues  of  the  body  constitutes 
a  sort  of  scorbutus  of  syphilitic  origin.  Aside  from  the  bullse  and  general 
hemorrhagic  diathesis,  these  children  may  present  all  the  lesions  described  under 
the  head  of  fetal  syphilis. 

4.  General  Conditions. — Chronic  metal  poisoning  of  the  mother,  alcoholism, 
nicotinism,,  diabetes,  albuminuria  and  eclampsia,  and  the  cancerous  cachexia  all 
tend  to  the  production  of  weak,  undersized  fetuses  with  a  high  degree  of  secon- 
dary mortality.  Lead- poisoning,  alcoholism,  and  albumimtria  also  tend  specially 
to  cause  convulsions  and  bestow  a  highly  neuropathic  organization  upon  the 
child.  The  offspring  of  the  highly  neurotic,  hysterical,  epileptic,  and  psycho- 
pathic individual  also  develop  these  tendencies,  but  here  it  is  an  affair  of  pure 
heredity.  Children  who  appear  normal  at  birth  but  develop  tendencies  in  later 
life  are  not  included  under  the  pathology  of  the  newly  bom.  Ballantyne,  for 
the  same  reason,  does  not  describe  hereditary  chorea,  hereditary  ataxia.  Thorn- 
sen's  disease,  etc.,  under  affegtions  of  the  newly  bom.  In  regard  to  the  various 
local  diseases  which  develop  in  titero,  survival  is  largely  a  matter  of  accident. 
In  fetal  ichthyosis  of  the  grave  type,  for  example,  one  victim  of  the  disease 
lived  to  the  age  of  five  months.  Children  with  fetal  anasarca  have  lived  at 
most  but  a  few  days  after  birth.  An  infant  with  congenital  cystic  elephantiasis 
is  known  to  have  survived  for  twenty  months.  These  are  mere  curiosities  of 
medicine,  for  as  a  general  rule  children  with  the  aforesaid  affections  are  practi- 
cally still-bom,  living  at  most  but  a  few  minutes.  The  condition  known  as 
simple  congenital  elephantiasis,  characterized  by  overgrowth  of  the  soft  parts  of 
a  limb,  is  entirely  compatible  with  life.     The  same  is  true  of  the  mild  form 


810 


THE  PATHOLOGY  OF   THE  NEWLY   BORN. 


of  ichthyosis.  Other  congenital  affections  in  which  survival  readily  occurs  are 
keratolysis,  tylosis,  anomalies  of  the  pilous  system,  etc.  The  conditions  com- 
prised under  the  term  fetal  rickets  are  not  incompatible  with  life.  Children  bom 
with  ascites  seldom  survive,  but  this  is  due  principally  to  the  relative  impossi- 
bility of  birth  without  mutilation.  At  least  one  case  has  shown  that  this 
affection  is  not  per  se  incompatible  with  life.  In  peritonitis,  as  distinguished 
from  ascites,  a  brief  extrauterine  existence  has  been  recorded.  In  congenital 
obliteration  of  the  bile-ducts  the  children  may  survive  for  a  longer  or  shorter 
interval,  but  the  prognosis  is  almost  hopeless,  and  the  same  is  true  of  congenital 
hypertrophic  stenosis  of  the  pylorus  in  which  three  months  is  considered  the  limit 
of  life.  In  fetal  endocarditis  there  is  an  indefinite  period  of  survival  with  occa- 
sional recovery.  Nephritis  contracted  apparently  in  utero  proves  fatal  within  a 
short  time  after  delivery ;  one  infant  lived  twenty-one  days.  If  the  degree  of 
hydrocephalus  is  not  too  extensive  to  prevent  birth  alive,  or  if  the  disease  is 
just  beginning,  the  patients  may  survive  for  some  years.  It  is  evident  that 
the  group   of  diseases   of  intrauterine  origin  which  persist  into   extrauterine 

existence  is  not  one  of  great  importance. 
The  most  important  is  hydrocephalus, 
which,  while  of  intrauterine  origin,  per- 
sists as  one  of  the  most  important  dis- 
eases of  infancy.  Congenital  debility, 
characterized  by  small  size  and  low 
weight,  evidences  of  prematurity,  sub- 
normal temperature,  etc.,  while  not  a 
disease,  is  a  very  common  and  import- 
ant legacy  of  the  antenatal  period  which 
may  arise  from  a  host  of  maternal  con- 
ditions and  which  may  predispose  the 
individual  to  an  early  death  under  a 
variety  of  forms. 

5.  Infantile  Syphilis. — Syphilis  in  in- 
fants is  either  congenital  or  a  postnatal 
infection.  (See  Antenatal  Syphilis,  page 
259.)  In  the  first  instance  it  is  heredi- 
tary; in  the  second,  an  acquired  disease 
with  initial  lesion  and  its  sequences, 
which  do  not  differ  from  those  of  later  life  except  in  the  modifications  which 
fetal  tissue  may  bring  about.  Heredity  is  seen  following  syphilis  of  one  or 
both  parents.  Infection  from  the  father  is  most  frequent  and  least  severe,  be- 
cause influence  ceases  with  impregnation.  It  is  most  depressing  in  double 
heredity,  but  maternal  cases,  owing  to  the  nine  months  of  interchange  between 
the  fluids  of  the  fetus  and  the  mother,  show  a  mortality  almost  as  high.  Ac- 
cording to  Foumier's  statistics  of  five  hundred  cases,  one-third  are  fatal  from 
transmission  from  the  father,  60  per  cent,  from  the  mother,  and  68  per  cent,  in 
mixed  descent.  These  figures  are  very  materially  modified  by  prompt  treat- 
ment.    For  pathology  and  symptoms,  see  Antenatal  Syphilis,  Part  III. 

Diagnosis. — To  aid  in  the  diagnosis  of  early  inherited  syphilis,  there  may  be  a 
history  of  disease  or  evident  efflorescence  in  one  or  both  parents,  or  the  tale  of 
repeated  abortion  may  be  elicited  at  progressively  retarded  periods,  the  fetuses 
being  macerated,  shriveled,  with  enlarged,  lobulated  livers,  skin  eruptions,  or 
hydrocephalus.  The  infant  presents  signs  of  the  disease  at  birth  or  they  develop 
in  a  few  days.     It  may  be  rosy  and  well  nourished,  but  is  oftenest  emaciated,  gray 


Fig.  1006. — Syphilitic  Pemphigus  in  the 
Newly  Born. ^{Lepage.) 


ANTENATAL  AFFECTIONS  IN  EXTRAUTERINE  LIFE.         811 

in  hue,  with  a  senile  facies.  The  palms  and  soles  show  red  areas  on  which  bullae 
develop,  moist  papules  are  seen  around  the  anus  and  mouth,  the  mouth  is  filled 
with  sores.  The  baby  has  difficulty  in  nursing,  breathes  through  the  mouth,  and 
snuffles  continually.  The  cry  is  feeble  and  hoarse;  there  may  be  a  persistent 
bronchitis.  The  eyes  present  no  symptoms  or  there  are  a  ciliary  injection  and 
photophobia.     The  end  of  one  or  more  of  the  long  bones  shows  an  inflammatory 

yat   Periosteum 


Fig.  1007. — Syphilitic  Osteochondritis  in  the  Newly  Born.  Longitudinal  Section. 
X  100. — {From  a  specimen  in  the  Pathological  Laboratory  of  the  Cornell  University 
Medical  College.) 


enlargement.     All  symptoms  may  be  absent  when   a  parent  is  known  to  be 
syphilitic.     The  child  must  then  be  watched  for  developments  (Fig.  1006). 

Prognosis.— This  is  practically  entirely  dependent  on  treatment  if  the  child  is 
viable.  Mortality  in  maternal  descent  is  reduced  from  60  to  3  per  cent.  Re- 
currence is  unfortunately  apt  to  occur,  and  in  the  shape  of  destructive  lesions 
later  in  life,  but  the  large  percentage  of  relapses  is  due  to  insufficient  medication 


812  THE  PATHOLOGY  OF   THE  NEWLY  BORN. 

at  the  outset.  Certain  cases  succumb  to  marasmus  in  spite  of  all  that  can  be  done. 
As  to  the  viability  of  a  fetus,  the  prognosis  is  better  as  the  parental  syphilis 
increases  in  age  and  as  attention  has  been  paid  to  treatment.  Much  can  be 
done  in  the  way  of  prevention  by  careful  mercurialization  of  the  mother  during 
pregnancy. 

Treatment. — Inunction  should  be  instituted  as  soon  as  the  diagnosis  is  made. 
It  is  best  done  by  smearing  mercurial  ointment  under  the  belly-band,  where  the 
child's  movements  will  cause  its  absorption.  The  white  precipitate  or  blue 
ointment  maybe  used,  a  half-drachm  of  either,  mixed  with  an  equal  part  of  lanolin, 
daily  until  the  symptoms  have  disappeared,  then  every  other  day  for  a  month. 
After  that  time  the  inunctions  are  continued  with  intermissions  for  a  year, 
or  internal  medication  in  the  form  of  gray  powder  or  the  protiodid  or  tannate 
may  be  substituted.  It  is  well  while  mercury  is  being  given  systematically  to 
administer  a  little  iron  from  time  to  time  in  the  shape  of  the  syrup  of  the  iodid. 
It  is  not  enough  to  medicate  the  mother.  The  method  is  inaccurate  and  most 
unscientific,  but  there  is  small  hope  for  the  child  if  she  does  not  nurse  it.  Wet- 
nursing  is  not  to  be  considered  on  account  of  contagion,  unless  the  nurse  is 
syphilitic.  Medication  should  be  continued  for  at  least  a  year,  but  the  child 
should  be  kept  under  observation  for  two  j'-ears. 


III.  AFFECTIONS  WHICH  ORIGINATE  INTRA   PARTUM. 

I.  Asphyxia  Neonatorum.  2.  Birth  Traumatisms.  j.  Aspiration  Pneumonia.  4.  Con- 
tagious Diseases  Contracted  from  the  Mother.  (7)  Ophthalmia  Neonatorum.  (2)  Gonor- 
rheal Stom-atitis. 

Here  belong  most  of  the  cases  of  asphyxia,  the  various  birth  traumatisms 
aspiration  pneumonia,  and  contagious  diseases — chiefly  gonorrhea — contracted 
from  the  mother  sub  partu.  So-called  intranatal  affections  constitute  a  well- 
defined  group  which  in  general  bears  little  relation  to  antenatal  or  neonatal 
disease.  Some  confusion  may  occur  in  the  case  of  sepsis,  which  may  be  con- 
tracted at  any  period  of  existence,  whether  intrauterine  or  extrauterine.  The 
pathogenic  factors  which  operate  intra  partum  may  be  mechanical  or  bac- 
terial. The  former  consist  largely  of  compression  of  the  fetus,  either  by  the 
maternal  passages  or  by  the  forceps,  and  of  traction  by  the  medical  attendant  or 
of  aspiration  by  the  fetus  of  liquor  amnii.  The  latter  comprise  a  number  of 
germ  infections,  one  of  which,  however,  stands  out  with  prominence  over  all 
others:  viz.,  gonorrheal  ophthalmia.  The  mechanical  element  is  equivalent  to 
the  entire  subject  of  dystocia.  The  immediate  results  of  mechanical  compression 
may  be  general  or  local.  There  are  but  two  examples  of  the  general  character. 
(i)  Asphyxia:  Here  the  compression  is  of  such  a  character  that  the  aeration  of 
the  fetal  blood  becomes  arrested.  (2)  Apoplexy:  Compression  of  the  skull  some- 
times leads  to  endocranial  hemorrhage,  which  may  cause  the  death  of  the  fetus, 
or,  if  the  latter  survives,  paralysis. 


I.  ASPHYXIA  NEONATORUM. 

Synonyms  :  Apnoea  neonatorum ;  asphyxia  nascentium. 

Introduction. — This  subject,  at  first  sight  one  of  great  simplicity,  is  in  reality 
one  of  the  most  difficult  in  the  entire  subject  of  obstetrics.  The  simple  and 
straightforward  manner  in  which  it  is  presented  by  the  great  majority  of  authors 


AFFECTIONS -WHICH  ORIGINATE  INTRA  PARTUM.  813 

involves  a  discreet  suppression  of  numerous  problems  which  would  otherwise 
confuse  and  perplex  the  student.  Nevertheles^s  I  deem  it  the  wiser  plan  to  face 
these  difficulties  and  to  attempt,  at  least,  to  distinguish  between  what  is  clear 
and  what  is  obscure.  Asphyxia  neonatorum  is  one  of  the  neglected  connecting 
links  between  two  specialties — obstetrics  and  pediatrics.  Each  one  of  these  has 
apparently  been  perfectly  willing  to  abandon  its  care  of  this  subject  to  the 
other;  each  has  considered  it  in  a  fragmentary  way.  The  result  has  been  that 
important  phases  of  the  subject  still  await  investigation  and.  our  knowledge  of 
it  is  imperfect. 

Definition. — Before  a  definition  can  be  made  it  will  be  necessary  to  analyze 
the  meaning  of  the  terms  in  use.  What  is  meant  by  asphyxia,  whether  the 
word  is  used  in  a  general  sense  or  refers  only  to  the  newly  born,  is  practically 
defective  aeration  of  the  blood,  and  this  deficiency  may  be  slight  or  extreme. 
While  I  do  not  advise  the  doing  away  with  a  term  so  universally  employed  as 
asphyxia,  I  prefer,  when  possible,  to  substitute  some  such  expression  as 
"subaeration."  The  term  apnea,  which  has  been  proposed  as  a  substitute  for 
asphyxia,  is  open  to  the  same  objection  as  the  latter  word,  and  Ahlfeld  has  sug- 
gested that  it  be  used  to  represent  the  physiological  inactivity  of  the  fetal  lungs 
up  to  the  time  of  ligation  of  the  cord.  Such  terms  as  "suspended  animation" 
and  "apparent  death,"  often  proposed  as  substitutes  for  asphyxia  neonatorum, 
appear  to  be  even  more  objectionable  than  the  latter,  and,  as  a  matter  of  fact, 
all  the  synonyms  and  substitutes  thus  far  proposed  appear  to  be  applicable  only 
to  the  terminal  stage  of  subaeration  of  the  blood. 

Varieties. — The  subject  of  asphyxia  neonatorum  consists  of  a  number  of 
different  conditions  which  have  a  common  tendency.  Thus,  when  the  child 
is  in  utero  and  labor  is  not  impending  various  agencies  may  compress  the  cord 
and  bring  about  the  death  of  the  fetus.  Such  a  state  of  affairs  might  be  termed 
"subaeration  from  cord  compression  ante  partum  "  and  might  be  fatal  im- 
mediately, or  if  the  constriction  were  not  complete,  a  chronic  condition  would 
be  set  up,  manifested  by  some  form  of  arrested  development.  Under  these 
circumstances  the  term  "intrauterine  asphyxia"  would  apply.  If  the  child  is 
alive  and  well  up  to  the  moment  of  the  onset  of  labor,  and  during  this  act  the 
cord  is  compressed,  we  should  then  have  a  condition  of  subaeration  from  cord 
compression  intra  partum.  If  the  subaeration  were  complete,  the  child  would 
be  dead  long  before  it  could  be  extracted;  but  if  only  partial  or  temporary,  it 
might  be  possible  to  reanimate  the  child  after  delivery.  The  cord  being  free 
from  compression,  the  very  act  of  labor  itself  in  compressing  the  skull  and 
thorax,  and  the  added  compression  of  the  forceps  when  the  latter  is  applied, 
will  give  rise  to  a  condition  which  may  be  described  as  "subaeration  from  com- 
pression of  the  skull  (intra  partum)."  What  has  been  said  of  cord  compression 
applies  equally  to  disturbance  of  placental  circulation  i;/  situ,  and  pre- 
mature detachment  of  placenta.  Some  cases  of  this  form  are  simple,  others 
are  complicated  by  intracranial  hemorrhage ;  so  that  the  children  are  bom  both 
asphyxiated  and  with  paralyses  of  central  origin.  It  is  probable  that  most  of 
the  infants  that  are  born  in  a  state  of  subaeration  from  which  they  may  be  re- 
animated are  examples  of  simple  compression  of  the  skull.  If  the  child  is 
bom  alive  and  does  not  begin  to  respire  until  the  cord  is  'cut,  the  condition 
has  been  termed  physiological  apnea.  Many  children  utter  no  cry  at  birth 
and  respiration  is  so  shallow  that  it  escapes  observation.  This  is  known  as 
"false  asphyxia."  The  child  is  doubtless  in  a  condition  of  subaeration  because 
the  cord  has  been  cut  and  the  breathing  is  incomplete.  From  the  fact  that 
these  children  soon  begin  to  breathe  more  naturally,  the  condition  may  be 


814 


THE   PATHOLOGY  OF   THE  NEWLY   BORN. 


regarded  as  physiological.  This  class  of  cases  doubtless  passes  by  imperceptible 
degrees  into  a  more  serious  one,  especially  noted  in  congenitally  feeble  and 
premature  children.  Here  the  child  attempts  to  breathe,  but  is  unequal  to  the 
task  of  aerating  its  blood.  It  becomes  cyanotic  and  succumbs  at  a  variable 
period  after  birth.     This  might  be  termed  "subaeration  from  prematurity  or 

debility, post  partum."  When 
we  consider  that  two  or  more 
of  the  preceding  types  of  sub- 
aeration  may  coexist  in  the 
same  child,  the  extreme  com- 
plexity of  the  subject  is  ap- 
parent. The  list  might  also 
be  extended;  thus,  fetal  sub- 
aeration  is  doubtless  present 
in  certain  diseases  of  the 
mother,  especially  in  convul- 
sions, and  in  any  maternal 
affection  in  which  the  blood  is 
imperfectly  aerated,  particu- 
larly in  cardiac  and  pulmon- 
ary diseases.  Again,  during 
labor  chloroform  narcosis 
may  favor  subaeration  in  the 
fetus. 

Pathology.  —  Pathological 
changes  may  be  due  to  the  as- 
phyxia itself,  in  which  case 
the  blood  is  fluid,  the  right 
heart  engorged,  and  the  large 
thoracic  vessels,  sinuses  of  the 
dura,  and  hepatic  vessels  are 
in  a  state  of  distention.  Ex- 
travasations often  accom- 
pany the  distention,  especi- 
ally in  the  viscera,  and  oedema 
has  been  noted  in  the  pia, 
scrotum,  and  cord.  Another 
set  of  pathological  changes  is 
found  in  the  thoracic  organs 
in  cases  in  which  premature 
respiration  has  occurred.  In 
these  cases  the  trachea  and 
bronchi  may  be  filled  with 
mucus,  amniotic  fluid,  meco- 
nium, etc.  (Fig.  1008).  Such 
substances  constitute  a 
demonstration  of  the  fact 
that  intrauterine  respiration  has  occurred.  These  fluids  may,  however,  be  pre- 
vented from  entering  the  trachea  by  the  interposition  of  the  membranes  or  the 
close  contact  of  the  maternal  parts.  The  stomach  may  also  contain  meconium. 
Pulmonary  ecchymoses  are  less  frequent  here  than  in  post-natal  asphyxia.  In 
this  form  the  evidences  of  premature  respiration  are  absent.     General  atelectasis 


Fig.  1008. — Respiratory  Organs  and  Heart  of  a 
Full-term  Child  Who  Died  During  Labor  of 
Intrauterine  Asphyxia  from  Premature  Respi- 
ration Caused  by  Probable  Compression  of  the 
Umbilical  Cord,  i,  Aspired  Tneconium  in  the  res- 
piratory passages;  2,  numerous  areas  of  ecchymoses 
of  asph}oda  in  the  heart  and  lungs. — (Hofntann.) 


AFFECTIONS  WHICH  ORIGINATE  INTRA   PARTUM. 


815 


will  be  found,  even  in  children  who  have  been  reanimated.  The  pathological 
changes  in  the  intrauterine  form  are  analogous  to  those  of  ordinary  suffocation. 
The  blood,  which  is  thin,  fills  the  cerebral  sinuses.  The  membranes  are  oedema- 
tous.  The  lungs  have  a  dark  hue  and  the  respiratory  passages  are  filled  with 
liquor  amnii  and  debris.  Occasionally  air  is  found  in  the  lungs.  Extravasations 
and  ecchymoses  are  found  in  the  various  organs,  which  are  congested  (Fig.  1008). 
Soft,  dark  clots  distend  the  right  heart.  In  the  extrauterine  form  we  often  find 
large  areas  of  atelectasis  in  the  lungs.  There  will  be  visible  the  external  signs 
of  the  forces  that  have  produced  the  condition.  The  organs  exhibit  structural 
changes.  The  lungs  and  heart  as  well  as  the  diaphragm  and  brain  are  often  im- 
perfectly formed.  Intrauterine  pneumonia  or  pleurisy  may  be  present.  When 
ineffectual  respiratory  efforts  have  occurred,  the  lungs  are  more  markedly  con- 
gested and  numerous  hemorrhages 
are  scattered  over  the  visceral 
pleura.  -The  lungs  are  engorged 
to  such  an  extent  that  they  are 
heavier  than  water;  when  immersed 
they  sink  at  once.  One  proof  of  pre- 
mature respiratory  efforts  is  the 
presence  of  a  greenish  fluid  which 
may  be  pressed  from  the  cut  surface 
of  the  lungs  and  which  may  be 
found  in  the  trachea. 

Etiology.  —  Anything  which 
tends  to  interrupt  the  flow  of  blood 
toward  the  fetus  through  the  pla- 
centa and  cord  will  shut  off  its  oxy- 
gen. Hence,  either  compression  of 
the  cord  or  premature  separation  of 
the  placenta  is  the  most  natural 
cause  of  asphyxia.  Tetanoid  con- 
tractions of  the  uterus  in  which  the 
muscular  action  is  continuous  will 
also  arrest  the  placental  circulation. 
Another  condition  under  which  as- 
phyxia may  develop  is  the  so-called 
"vaginal  birth"  which  occurs  at 
times  in  breech  presentations. 
Here  the  placental    circulation   is 

interrupted  while  the  head  is  still  in  the  vagina  and  remote  from  atmos- 
pheric air.  There  are  a  number  of  conditions  which  favor  the  development  of 
asphyxia  and  which  are  divisible  into  maternal  and  fetal.  Such  conditions  do 
not  produce  a  forcible  shutting-off  of  the  oxygen  supply,  and  the  mechanism 
by  which  asphyxia  develops  in  these  cases  is  by  no  means  clear.  There  occurs 
a  suppression  in  the  amount  of  oxygen  which  reaches  the  fetus,  either  because 
of  scarcity  of  that  substance  in  the  maternal  blood,  or  of  some  anomaly  of  the 
fetal  organs  which  interferes  with  the  oxj^genation  of  the  blood.  Hemorrhage 
in  the  mother,  by  greatly  reducing  the  number  of  red  corpuscles,  and  thereby 
interfering  with  the  oxygen  supply,  becomes  a  cause  of  asphyxia.  In  fetal 
asphyxia  from  eclampsia  the  shutting-off  of  the  oxygen  supply  might  be  due 
to  interference  with  maternal  respiration  or  to  a  tetanic  condition  of  the  uterus. 
Only  after  the  fetus  is  born  can  the  various  conditions,  such  as  persistence 


Fig.  1009. — Face  of  a  Newly  Born  Child 
Covered  by  a  Portion  of  the  Membranes. 
A  possible  cause  of  asphyxia  in  the  newly 
born. 


816  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 

of  the  foramen  ovale,  atresia  of  the  pulmonary  artery,  etc.,  come  into  play. 
Causes  from  interference  with  pulmonary  respiration  begin  to  be  operative 
before  delivery  to  the  extent  that  the  entrance  of  maternal  secretions,  meconium, 
etc.,  into  the  breathing  passages  may  obstruct  the  first  efforts  at  respiration.  Per- 
sistence of  the  membranes  unruptured  will  have  the  same  effect;  likewise  the 
fact  of  so-called  vaginal  birth  (Fig.  1009).  Again,  when  the  child  first  attempts 
to  breathe  by  the  lungs  the  presence  of  a  disease  or  malformation  may  be  evident 
for  the  first  time;  e.  g. ,  atresia  of  the  pulmonary  artery,  persistence  of  the  foramen 
ovale,  congenital  atelectasis.  An  entirely  different  mechanism  obtains  in  asphyxia 
from  brain  compression.  When  there  are  no  evidences  of  interference  with  pla- 
cental circulation  through  the  agencies  already  described,  we  are  forced  to  explain 
asphyxia  due  to  brain  compression  by  the  profound  slowing  of  the  fetal  heart 
which  diminishes  the  oxygen  received  to  such  an  extent  as  to  cause  death.  It 
is  claimed  that  compression  of  the  skull  paralyzes  the  respiratory  center. 

Symptoms. — The  phenomena  known  collectively  as  asphyxia,  subaeration, 
oxygen-hunger,  etc.,  however  produced,  are  essentially  the  same  in  nature, 
presenting  every  degree  of  intensity  from  mere  irregularity  and  superficiality 
of  breathing  to  a  condition  of  apparent  death.  Despite  this  gradation  in 
intensity  of  manifestation,  the  great  majority  of  authors  still  cling  to  the  old 
fundamental  subdivision  of  blue  and  white  asphyxia.  The  former  term  indicates 
a  condition  of  cyanosis,  but  differs  from  the  white  or  anemic  variety  not  so 
much  in  color  as  in  the  behavior  of  the  muscular  system,  the  latter  preserving 
its  tonus  in  the  blue  type,  while  in  the  white  asphyxia  a  state  of  complete  mus- 
cular relaxation  exists.  Blue  asphyxia  or  cyanosis  due  to  a  sudden  accumula- 
tion of  carbonic  acid  in  the  blood  is  believed  to  pass  naturally  into  the  anemic 
or  white  stage,  which  is  therefore  held  to  be  the  terminal  manifestation;  yet  this 
distinction  is  of  little  value  in  practice  because  in  the  white  variety  it  is  not 
only  often  possible  to  resuscitate  children  thus  bom,  but  spontaneous  recovery 
under  these  circumstances  is  far  from  exceptional.  I  am  in  favor  of  doing  away 
with  the  color  test  or  blood  test,  and  of  placing  the  chief  reliance  upon  the 
state  of  the  muscles  in  determining  the  degree  of  subaeration.  In  mild  or 
medium  degrees  of  the  latter  the  pharyngeal  reflex  is  preserved,  while  in  the 
highest  degrees  it  is  absent.  Whether  or  not  there  is  coniplete  concordance  be- 
tween the  state  of  the  blood  and  the  condition  of  the  musculature  does  not  appear 
to  have  been  determined.  When  the  pharyngeal  reflex  is  absent,  the  lower 
jaw  hangs  loose.  Another  test  of  extreme  asphyxia  is  found  in  the  failure 
of  the  heart  to  respond  to  the  various  forms  of  cutaneous  stimulation.  The 
blue  asphyxia  is  characterized  clinically  by  a  livid  redness  or  blueness  of  the 
face  and  upper  parts  of  the  body.  The  face  is  turgescent  and  the  eyeballs  are 
prominent  and  injected.  The  muscles  of  the  extremities,  neck,  and  jaws  are 
rigid,  and  the  heart  action  is  strong.  In  children  thus  born  the  cord  is  found 
to  pulsate  strongly.  The  reflexes  and  sphincters  behave  in  a  normal  manner. 
Children  bom  with  blue  asphyxia  may  recover  promptly  or  only  after  a  con- 
siderable interval;  or  the  condition  may  pass  into  the  white  or  anemic  fonn. 
Here  the  condition  superficially  present  in  blue  asphyxia  appears  to  be  inverted. 
The  surface  is  pale  instead  of  livid.  The  face  is  pinched,  the  muscles,  includ- 
ing the  sphincters,  are  all  relaxed.  Circulation  is  at  a  standstill,  and  not  only 
is  the  heart-beat  difficult  to  recognize,  but  there  is  no  escape  of  blood  when 
the  surface  is  incised.  Children  bom  with  white  asphyxia  have  a  small,  almost 
pulseless  cord.  All  in  all,  the  subject  of  the  symptomatology  of  asphyxia 
neonatorum  is  in  a  most  unsatisfactory  state. 

Diagnosis. — -Diagnosis  before  delivery  is  made  (i)  by  the  aid  of  information 


AFFECTIONS.WHICH  ORIGINATE  INTRA  PARTUM  817 

afforded  by  the  fetal  heart-sounds,  which  undergo  alterations  in  quality  and 
frequency;  (2)  by  the  presence  of  meconium  in  the  discharges  (except  in  breech 
presentations),  and  occasionally  (3)  by  the  intrauterine  cry  heard  in  the  lower 
part  of  the  canal  or  the  evidence  of  respiration  in  the  same  locality.  Diagnosis 
after  delivery  is  made  by  recognition  of  the  clinical  picture  of  diminution  or 
absence  of  circulatory  and  respiratory  phenomena.  In  regard  to  vaginal  birth, 
inspiratory  efforts  of  the  fetus  while  the  head  is  in  the  vagina  are  betrayed 
by  a  peculiar  quivering  of  the  skull  (in  head  presentations).  In  this  connection 
it  should  be  stated  that  this  phenomenon  is  equivalent  to  an  indication  to 
terminate  labor  immediately. 

Prognosis. — As  long  as  there  is  cardiac  action  there  is  hope  of  resuscitation. 
Generally  speaking,  the  prognosis  is  always  grave,  varying  with  the  degree 
of  asphyxia.  Spontaneous  efforts  at  respiration  constitute  a  favorable  sign. 
It  must  be  remembered  that  the  failure  of  respiration  may  be  owing  not  to 
ordinary  asphyxia,  but  to  another  affection,  such  as  a  trauma  affecting  the 
respiratory  center,  atelectasis,  intracranial  hemorrhage,  etc.  If  efforts  at  re- 
animation  are  successful,  the  prognosis  is  still  far  from  favorable,  as  death 
frequently  occurs  from  atelectasis,  paralysis,  convulsions,  pneumonia,  etc. 
Regarding  the  prognosis  in  utero,  we  should  not  forget  that  the  interruption 
of  the  placental  circulation  may  be  only  temporary.  The  tendency  of  the 
child  to  make  inspiratory  efforts  whenever  the  placental  circulation  is  interfered 
with  is  not  one  of  self-preservation,  for  the  asphyxia  is  thereby  rendered  worse, 
since  the  blood  is  forced  from  the  right  heart  into  the  lungs.  On  the  other 
hand,  the  aspiration  of  amniotic  fluid,  etc.,  does  no  harm,  but  tends  to  inhibit 
the  respiratory  movements. 

TREATMENT. 

Prophylaxis. — This  includes  everything  which  tends  to  promote  eutocia, 
such  as  correction  of  malposition  before  labor  is  under  way;  acceleration  of 
delivery  by  manual  compression;  correction  of  positions  which  threaten  im- 
paction; speedy  relief  of  spastic  rigidity  of  the  cervix  ;  preservation  of  the  bag  of 
waters;  avoidance  of  abuse  of  chloroform.  Here  also  belongs  the  proper  man- 
agement of  the  child  after  birth.  Extreme  measures  have  sometimes  been 
recommended  or  practised  for  the  prevention  of  asphyxia.  Thus,  Rapin  per- 
formed insufflation  of  the  amniotic  sac  on  a  number  of  occasions.  He  introduced 
the  air  by  means  of  a  catheter  and  syringe,  500  to  600  c.c.  at  a  time.  It  is  self- 
evident  that  the  air  could  not  enter  the  uterine  sinuses,  protected  as  they  were 
by  the  amnion.  Rapin  claims  good  results.*  A  still  more  radical  procedure  is 
the  performance  of  tracheotomy  when  during  a  breech  delivery  the  head  is  ar- 
rested at  the  brim.  By  means  of  a  tracheal  tube  the  lungs  may  be  inflated  and 
respiration  begin  in  this  locality. 

Curative  Treatment. — Here  we  have  four  well-defined  indications — namely: 
(i)  immediate  delivery,  the  diagnosis  of  intra-partum  asphyxia  having  been 
made  (page  S16);  (2)  removal  of  foreign  substances  from  the  respiratory  pas- 
sages immediately  upon  the  birth  of  the  child;  (3)  the  restoration  of  respiration 
by  reflex  stimuli,  artificial  respiration,  or  insufflation  of  the  lung;  (4)  treatment 
of  shock. 

I.   Immediate    Delivery. — The  choice  of  means  will  in  most  cases  be  in 

favor  of  the  forceps.     Often  a  preliminary   bimanual  completion   of  cervical 

dilatation  will  be  demanded.     After  the  expulsion  of  the  child,  if  cyanosis  is 

evident,  the  cord  should  be  divided  at  once  and  allowed  to  bleed  about  an 

*  "Ann.  de  gyn.  et  d'obst6t.,"  Sept.,  1S99. 

52 


818 


THE  PATHOLOGY  OF   THE  NEWLY  BORN. 


ounce.  It  should  be  remembered,  however,  that  imimediate  Hgation  of  the  cord 
is  in  itself  equivalent  to  depriving  the  child  of  an  ounce  of  blood.  In  the  anemic 
form  of  asphyxia  we  should  cover  the  child  with  hot  flannels  and  wait  for  the 
pulsations  of  the  cord  to  cease. 

2.  Removal  of  Foreign  Substances  from  the  Air-passages. — The 
second  indication  is  to  cleanse  the  respiratory  passages  of  fluids  aspirated 
during  labor.  This  can  be  accomplished  in  part  by  inverting  the  child  and 
swabbing  out  its  mouth  with  the  little  finger  wrapped  in  gauze  (Figs,  loio,  loii). 
The  contents  of  the  nose  should  be  squeezed  out.     This  cleansing  of  the  mouth 

and  nasal  passages  should  be  begun  as  soon 
as  the  head  is  born.  Some  obstetricians 
claim  ihat  respiration  is  the  best  and  most 
rational  means  for  cleansing  the  lower  air- 
passages.  Hence  after  the  preliminaries 
just  described  they  either  attempt  to  excite 
natural  respiration  by  reflex  stimuli,  or  in 
more  serious  cases  proceed  at  once  to  arti- 


Fig.  ioio. — Suspension  of  the  As- 
phyxiated Newly  Born  Child  by 
THE  Feet  to  Assist  Gravity  in 
Freeing  the  Air-passages  of  For- 
eign Matter. 


Fig.  ioii. — Suspension  of  the  Asphyxiated 
Newly  Born  Child  by  the  Feet,  and  Clear- 
ing the  Posterior  Pharynx  of  Foreign 
Matter  with  the  Little  Finger  Wrapped 
WITH  Gauze. 


ficial  respiration.  Other  authorities  believe  in  the  advisability  of  direct  aspiration 
of  the  secretions  by  special  devices  or  by  an  ordinary  catheter.  This  last  practice 
I  am  accustomed  to  follow.  The  same  apparatus  may  be  used  to  aspirate  the 
larynx  and  perform  insufflation.  All  attempts,  however,  to  enter  the  larynx 
should  be  frowned  upon.  Practice  upon  the  cadaver  will  readily  impress  one 
with  the  barbarousness  of  such  an  attempt  upon  the  newly  bom  child.  The 
most  that  can  be  accomplished  by  aspiration  is  the  removal  of  mucus  from  the 
lower  part  of  the  pharynx.  A  No.  6  catheter  may  be  made  to  answer,  into  the 
middle  of  which  I  insert  a  pipette,  so  that  its  bulbous  expansion  catches  the 


AFFECTIONS-  WHICH  ORIGINATE  INTRA   PARTUM.  819 

aspirated  fluids  which  might  otherwise  enter  the  operator's  mouth  (Fig.  1012). 
If  a  catheter  is  used,  it  should  be  open  at  the  end. 

3.  Restoration  of  Respiration. — (i)  Reflex  Stimuli. — The  third  indi- 
cation in  the  treatment  of  asphyxia  is  to  excite  the  respirations.  There  are 
two  methods  of  doing  this:  viz.,  reflex  stimulation  and  artificial  respirat  on. 
The  former  may  suffice  in  mild  cases.  The  usual  forms  of  stimuli  applied 
include  blowing  in  the  face,  slapping  the  buttocks,  sprinkling  or  immersing, 
hot  and  cold  water  being  used  alternately.  The  child  being  nearly  immersed 
in  warm  water,  cold  water,  alcohol,  or  ether  may  be  dropped  from  a  height 
on  the  exposed  chest.  Laborde's  method  of  tongue  traction  is  really  a  reflex 
stimulus,  although  usually  classified  under  artificial  respiration.  Cooke's 
method  of  dilating  the  anus  with  the  finger  also  belongs  here. 

(2)  Artificial  Respiration. — The  various  methods  now  in  vogue  are  as  follows: 
(a)  Byrd's  Method. — Dr.  Byrd  *  described  a  method  of  artificial  respiration 
as  follows :  "  Bring  the  ulnar  sides  of  the  hands  together  with  the  palmar  surfaces 
looking  vertically;  then  prop  them  beneath  the  back  of  the  infant  so  that  the 
extended  thumbs  may  aid  as  far  as  possible  in  sustaining  the  vertex  and  inferior 
extremities.  Then,  keeping  the  ulnar  borders  of  the  hands  in  contact  so  as 
to  form  a  fulcrum,  the  radial  borders  or  sides  are  simultaneously  depressed  to  as 
great  an  extent  as  practicable,  say  45  degrees,  below  the  horizontal  line,  and  then 
gradually  elevated  or  pronated  as  many  degrees  above  that  line,  thus  facilitating 


Fig.  1012. — Aspirator  for  Removing  Foreign  Matter,  as  Blood,  Mucus,  and  Meco- 
nium, FROM  THE  Posterior  Pharynx  by  Suction. 

the  escape  of  air  drawn  into  the  lungs  during  the  downward  movement  of  the 
head  and  chest.  These  movements  performed  in  a  regular  and  gentle  manner 
and  repeated  at  proper  intervals  seldom  fail  in  the  establishment  of  respiration 
where  it  is  possible  of  accomplishment."  Dr.  Byrd  gives  three  illustrations  of 
this  method.  Byrd's  method  has  been  somewhat  modified  in  the  past  thirty 
years,  principally  by  Dr.  Dew,  of  New  York,  so  that  to-day  it  is  often  performed 
as  follows:  It  should  be  remembered  that  Byrd's  method  can  be  carried  out  with 
the  child  in  a  warm  bath.  The  infant  is  grasped  with  the  right  hand,  the  neck 
supported  between  the  thumb  and  the  index-finger  (Fig.  1013).  The  head  is 
allowed  to  fall  backward  unrestrained.  The  palm  supports  the  shoulders  while 
the  three  last  fingers  in  the  axilla  lift  the  arm  upward  and  outward.  The  left 
palm  is  placed  beneath  the  thighs  with  the  fingers  grasping  the  knees  (Fig.  1014). 
Inspiration  is  induced  by  arching  the  body  of  the  child.  The  depression  of  the 
pelvis  and  lower  limbs  causes  descent  of  the  diaphragm  through  the  traction  upon 
the  abdominal  viscera,  while  flexion  at  the  upper  portion  of  the  vertebral  column 
elevates  the  ribs  and  separates  them.  Expiration  is  induced  by  reversing  the 
movements.  The  hyperextension  of  the  spine  is  changed  to  extreme  flexion  (Fig. 
1015).  The  elevation  of  the  head  and  shoulders  tends  to  approximate  the  ribs, 
while  extreme  flexion  of  the  thighs  crowds  the  diaphragm  upward  through  the 
pressure  of  the  abdominal  viscera.  At  the  completion  of  expiration  the  child 
should  be  inverted,  head  downward,  while  an  assistant  clears  the  mouth  and  nose 

*"  Baltimore  Med.  Jour.,"  1S70,  i,  646. 


820 


THE  PATHOLOGY  OF   THE  NEWLY   BORN. 


Fig.  1013. — Byrd's  Method  of  Artificial  Respira- 
tion.    Position  for  Inspiration. 


rr^- 


^^^ 


of  any  accumulated  mucus  with  a  gauze- wrap^jed  finger  (Fig.  1015).  Byrd's 
movements  should  be  repeated  six  or  eight  times  a  minute.  If  properly  per- 
formed, the  air  can  be  heard 
entering  the  glottis  during 
artificial  inspiration,  while 
expiration  often  results  in  the 
expulsion  of  aspirated  amni- 
otic fluid  and  mucus. 

(b)  Schultze's  Method. — 
This  has  been  recently  (1901) 
described  by  Schultze  himself 
as  follows:  The  child  lying 
upon  its  back  is  grasped  by 
the  shoulders,  the  open  hands 
having  been  slipped  beneath 
the  head.  The  last  three  fin- 
gers remain  extended  in  con- 
tact with  the  back  while  each 
index  is  inserted  into  an  ax- 
illa, the  thumbs  lying  upon 
and  in  front  of  the  shoulders 
(Fig.  1 01 6).  When  the  child 
thus  held  is  allowed  to  hang 
suspended,  its  entire  weight 
rests  upon  the  two  fingers  in 
the  arm-pits.  It  is  now  swung 
forward  and  upward,  the 
operator's  hands  going  to  the 
height  of  his  own  head,  the 
pelvic  end  of  the  child  rises 
above  its  head  and  falls  slowly 
toward  the  operator  by  its 
own  weight,  flexion  occurring 
in  the  lumbar  region  (Fig. 
1 01 6).  The  thumbs  in  front 
of  the  shoulders  compress  the 
chest  while  the  hyperflexed 
lumbar  vertebrae  and  pelvis 
compress  the  abdomen,  and 
through  it  the  thorax;  finally, 
the  last  three  fingers  on  each 
side  compress  the  thorax 
laterally.  As  a  result  of  this 
manoeuver  when  properly 
done,  aspirated  secretions 
flow  abundantly  from  the 
mouth.  The  distended  heart 
also  feels  the  compression, 
which   forces  the   blood  into 

Fig.  iois.-Byrd's  Method  of  Artificial  Respira-  ^     j^  ^^^^  i^g  ^^g- 

TioN.     Position  for  Expiration.     Note  the  mver-       .  .  .  .  j 

sion  of  the  child  to  assist  in  freeing  the  air-passages.       inal    position    and    supported 


/"' 


Fig.  1014. — Byrd's  Method  of  Artificial  Respira- 
tion. Position  between  Inspiration  and  Expi- 
ration. 


AFFECTIONS    WHICH  ORIGINATE  INTRA   PARTUM. 


821 


entirely  by  the  fingers  in  the  axilla  (Fig.  1016).  The  compression  of  the  thumbs 
and  last  three  fingers  is  removed.  The  downward  swing  elevates  the  sternum 
and  ribs  while  gravitation  and  the  traction  of  the  intestines  depress  the  dia- 
phragm. It  is  often  possible  to  hear  the  air  rush  into 
the  infant's  glottis  as  it  reaches  the  original  position, 
although  this  can  occur  in  a  cadaver.  The  amplifica- 
tion of  the  thorax  lowers  the  intracardiac  pressure. 
The  child  should  be  swung  up  and  down  ten  times  for 
the  space  of  a  minute.  The  effects  of  the  manoeuver 
should  be  as  follows:  The  heart-beat  increases  in 
frequency,  the  cadaveric  pallor  of  the  skin  becomes 
replaced  by  a  rosy  hue,  and  the  muscular  tonus  ap- 
pears. The  child  is  then  placed  in  a  warm  bath  and 
watched.  If  the  inspirations  are  superficial,  a  momen- 
tary dip  in  cold  water  is  indicated.  If  the  heart  action 
becomes  poor,  the  child  should  be  swung  again.  If  pro- 
longed swinging  becomes  necessary,  the  root  of  the 
tongue  should  be  compressed  forward  in  order  to  raise 
the  epiglottis  and  permit  the  removal  of  secretions 
with  the  fingers.  In  premature  children  the  thoracic 
walls  are  often  too  soft  to  benefit  by  the  compression 
of  the  fingers.  In  these  cases  insufflation  of  air  should 
be  practised. 

(c)  Sylvester's  Method  {Modified). — This  method  of 
artificial  respiration  requires  an  assistant.  The  child 
is  placed  on  its  back  with  the  head  supported  (not  to 
such  an  extent  that  the  chin  compresses  the  sternum). 
The  thorax  is  slightly  elevated  by  a  towel  placed  be- 
neath it.  The  feet  are  firmly  held  by  an  assistant 
with  a  towel.  The  physician  stands  behind  the  child 's 
head.  To  imitate  inspiration  the  arms  are  grasped 
near  the  elbows  and  brought  close  together  above  the 
head,  while  at  the  same  time  gentle  upward  traction  is 
made.  The  assistant  makes  counter-traction  upon  the 
feet.  The  movements  expand  the  ribs,  although  the 
change  in  the  intrathoracic  pressure  may  be  manifest 
at  first  only  by  retraction  of  the  abdomen.  If  the 
movements  are  continued  with  the  arms  somewhat 
everted  to  put  the  pectoralis  major  upon  the  stretch, 
the  air  gradually  begins  to  enter  the  chest.  Expira- 
tion is  imitated  by  bringing  the  elbows  down  and 
against  the  sides.  The  arms  are  somewhat  inverted, 
which  brings  the  forearms  across  the  chest.  The 
operator's  hands  also  make  compression  upon  the 
thorax,  so  that  air  is  forced  from  the  latter,  carrying 
perhaps  some  secretion  with  it.  The  movements  are 
made  at  the  rate  of  twenty  a  minute.  The  mouth 
should  be  wiped  out  from  time  to  time,  and  if  the 
passages  are  still  clogged  the  child  should  be  inverted 

and  the  chest  compressed.  If  spontaneous  respiration  begins,  the  movements 
must  be  timed  in  harmony  with  it;  this  is  of  vital  importance.  When  natural 
respiration  is  able  to  replace  artificial  measures,  it  should  be  assisted  by  ordinary 


Fig.  1016. — Schultze's 
Swinging  Method  of 
Artificial  Respira- 
tion. The  upper  figure 
is  the  position  of  expir- 
ation and  the  lower  that 
of  inspiration. 


822 


THE  PATHOLOGY  OF   THE  NEWLY  BORN. 


reflex  stimulation.     The  efficacy  of  this  method  is  shown  by  the  fact  that  it  can 
maintain  the  circulation  in  cases  in  which  the  respiratory  paralysis  is  complete. 

(d)  Prochownik's  Method. — The  child  is  held  inverted  by  the  legs,  the  opera- 
tor's right  hand  grasping  the  ankles  with  the  index  finger  between  (Fig.  1027). 
The  head  is  supported  below  to  an  extent  sufficient  to  produce  full  extension. 
Both  hands  of  an  assistant  compress  the  thorax  until  all  secretions  come  away. 
When  the  hold  on  the  thorax  is  released,  inspiration  takes  place.  After  repeating 
the  movements  six  or  eight  times  the  child  is  placed  in  a  hot  bath.  An  advan- 
tage of  Prochownik's  method  is  that  it  antagonizes  the  development  of  aspira- 
tion-pneumonia .  * 

(e)  Laborde's  Method. — This  consists  in  exciting  the  respiratory  center  by 
rhythmic  tractions  upon  the  tongue.     The  latter  is  drawn  out  with  the  fingers 


Fig.   1017. — Prochownik's  Method  of 
Artificial  Respiration. 


Fig.  1018. — Method  of  Infusing  Saline 
Solution  into  the  Umbilical  Vein  of  the 
Newly  Born  for  Some  Varieties  of  As- 
phyxia. 


(enveloped  in  a  piece  of  gauze)  some  fifteen  to  thirty  times  a  minute.  After 
each  act  of  traction  it  is  allowed  to  fall  back  into  its  customary  position.  It 
appears  to  stimulate  the  respiratory  center  through  the  proximity  of  the 
latter  to  some  of  the  other  medullary  centers  which  are  acted  upon  by  the 
tractions. 

(3)  Insufflation. — Opinions  as  to  the  utility  of  this  resource  are  of  great 
variance.  Some  mention  it  as  the  first,  others  as  the  last  resort.  It  may  be 
practised  with  or  without  instruments.  The  former  comprise  special  tracheal 
tubes  which  are  difficult  of  introduction,  and  apparatus  designed  to  cover 
the  nose  and  mouth  of  the  child.  An  ordinary  stethoscope  will  answer  the 
latter  purpose.     If  a  tube  is  used,  it  should  be  introduced  by  the  aid  of  a  finger 

*  This  author's  original  paper  may  be  consulted  in  the  "Ctbl.  f.  Gynakol.,"  1894, 
p.  226. 


AFFECTIONS  WHICH  ORIGINATE  INTRA   PARTUM.  823 

which  has  previously  located  the  arytenoid  cartilages.  If  the  tube  enters  the 
esophagus,  insufflation  will  inflate  the  belly.  In  insufflation  without  instru- 
ments— the  mouth-to-mouth  method — the  child  lies  supine  with  chest  elevated, 
as  in  Sylvester's  method  of  artificial  respiration.  The  operator  breathes  into 
the  mouth  through  gauze;  the  thorax  should  be  compressed  gently  after  each 
insufflation. 

(4)  Shock  Treatment. — The  fact  that  measures  that  belong  under  this 
head  are  of  such  value  in  asphyxia  apparently  justifies  the  theory  that  the  con- 
dition itself  possesses  a  considerable  element  of  shock.  These  measures  comprise 
the  application  of  heat,  either  dry  or  moist,  the  child  being  wrapped  in  hot  flannels 
or  immersed  in  hot  water;  hot  saline  infusion  into  the  rectum;  hypodermics  of 
brandy  (flve  or  six  drops)  or  of  strychnin  {-j^jj  grain). 

(5)  Umbilical  Infusion. — Success  has  attended  infusion  through  the  umbili- 
cal vein  after  all  the  customary  resources  have  proved  inefflcient.*  The  infusion 
is  something  more  than  an  ordinary  saline  solution,  for  Schiicking  added  fructo- 
sate  of  soda,  a  substance  which  is  believed  to  take  up  the  excess  of  carbonic  acid 
in  the  blood  with  the  formation  of  sodium  carbonate  and  sugar.  The  formula  used 
is  as  follows:  Fructosate  of  soda,  0.5;  sodium  chloride,  0.7;  boiled  water,  50  c.c. 
The  apparatus  employed  is  a  graduated  bottle,  a  tube,  and  a  cannula  (Fig.  loi  8). 
The  umbilical  vein  is  cut  across  and  the  cannula  inserted.  Thirty  cubic  centi- 
meters are  thrown  in  at  first,  followed  by  a  second  infusion  of  20  c.c.  As  soon 
as  the  heart  and  respiration  start  up,  ordinary  measures  are  resumed. 

Resume. — (i)  In  premature  and  feeble  children  Byrd's  method  of  artificial 
respiration  should  be  practised,  with  the  child  immersed  in  hot  water  or  between 
hot  flannels.  Insufflation  should  be  practised  by  the  mouth-to-mouth  method 
or  by  catheter.  (2)  In  the  apoplectic  or  livid  form  Byrd's  method  should  be 
used,  varied  with  a  few  swings  a  la  Schultze.  Lest  the  surface  become  chilled 
from  exposure,  the  child  should  then  be  placed  immediately  in  hot  water. 
(3)  In  the  anemic  or  pallid  form  Sylvester's  or  Byrd's  method  should  be  used, 
with  the  child  between  hot  flannels. 


2.  FETAL  TRAUMATISMS  OF  BIRTH. 

I.  Traumatisms  of  the  Brain  and  Cord. — Injuries  to  the  skull  and  brain 
are  due  to  obstructed  labor,  to  the  faulty  application  of  the  forceps,  or  to 
faulty  extraction  of  the  after-coming  head.  The  lesions  which  are  thus  brought 
about  comprise  simple  compression  of  the  brain  without  hemorrhage  (one  of 
the  chief  factors  in  the  production  of  intra-partum  asphyxia)  and  intracranial 
hemorrhage,  which  is  nearly  always  meningeal.  Naturally  the  results  of  com- 
pression often  coincide  with  hemorrhage,  so  that  to  asphyxia  are  conjoined  the 
consequences  of  effusion  of  blood  within  the  cranium. 

Cerebral  Apoplexy. — When  the  blood  is  extravasated  upon  the  surface 
of  the  brain  or  between  the  meninges,  the  term  meningeal  apoplexy  is  used; 
if  in  the  substance  of  the  brain,  cerebral  apoplexy.  No  small  number  of  infant 
deaths  either  during  or  closely  following  the  act  of  parturition  are  referred  to 
intracranial  hemorrhage.  Etiology:  Some  few  cases  are  due  to  syphilis,  and  in 
early  hemorrhages  the  exact  nature  of  which  has  not  been  definitely  determined 
direct  injury,  a  blow  or  a  fall  in  the  later  months  of  pregnancy,  and  the  accidents 
of  precipitate  labor  have  been  responsible  for  others;  but  the  great  majority  are 
in  some  manner  connected  with  tedious  labor,  whether  as  a  result  of  breech, 

*  Schucking:  "Ctbl.  f.  Gjmakol.,"  June  7,  1902. 


824  THE  PATHOLOGY   OF   THE  NEWLY   BORN. 

transverse,  or  brow  presentation,  contracted  pelvis,  insufficient  uterine  power, 
version,  the  too  early  rupture  of  the  membranes,  or  fetal  abnormalities.  The 
injudicious  and  indiscriminate  use  of  the  forceps  is  a  potent  factor.  Pathology: 
Within  the  skull  there  is  no  zone  of  freedom  from  hemorrhage  ;  it  may  be  epidural 
or  subdural,  within  the  meninges  or  in  the  brain  substance  itself.  It  occurs 
at  the  vertex  or  base,  and  varies  in  amount  from  very  small  extravasations 
to  those  which  cover  the  entire  brain  substance.  In  early  life  meningeal  hemor- 
rhage is  much  more  common  than  the  cerebral  variety  and  basal  hemorrhages 
greatly  outnumber  those  of  the  convexity.  The  most  common  seat  is  beneath 
the  pia  mater,  less  frequently  into  the  cavity  of  the  arachnoid,  the  blood  escaping 
in  these  situations  and  spreading  uniformly  in  all  directions.  Symptoms: 
The  symptoms  agree  quite  closely  with  the  pathological  conditions  jUst  described. 
They  are  more  uniform,  but  vary  according  to  the  seat  as  well  as  the  quantity 
of  the  effused  blood.  When  due  to  the  ordinary  causes  of  protracted  labor, 
the  infant  is  bom  apparently  dead,  resuscitation  is  gradual  and  difficult,  the 
cry  is  feeble,  the  eyes  are  motionless,  and  the  extremities  are  limp  and 
flaccid.  The  face  is  livid  or  pallid  and  the  respirations  are  gasping.  By  means 
of  hot  and  cold  baths,  artificial  respiration,  friction,  the  general  condition  of 
the  infants  may  show  slight  improvement,  but  ordinarily  they  succumb  after 
living  a  few  hours  or  a  few  days.  Depending  upon  the  distribution  of  the 
blood-clots  and  the  amount  of  intracranial  pressure,  various  degrees  of 
paralyses  of  the  face,  arms,  and  legs  may  occur,  and  convulsions  and  rigidity 
of  the  entire  body  are  often  present.  In  the  cases  which  survive  the  early 
days  of  life  the  rigidity  of  the  trunk  and  extremities  may  persist  and  the  degrees 
of  paralysis  may  be  definitely  determined.  In  favorable  cases  the  improvement 
goes  on  more  or  less  slowly  and  scarcely  ever  becomes  more  than  partial.  Con- 
tractures and  other  deformities  from  the  permanently  paralyzed  muscles  are 
sequelag  of  frequent  occurrence.  Prognosis:  If  the  infant  survives,  the  smaller 
extravasations  are  gradually  absorbed  and  the  surrounding  parts  tend  to  assume 
their  normal  functions.  Extensive  hemorrhage  is  usually  fatal.  As  a  rule,  the 
prognosis  depends  on  the  severity  of  the  early  symptoms ;  the  deeper  the  uncon- 
sciousness and  the  more  deficient  the  respirations  and  pulse,  the  less  the  prospect 
of  recovery.  Many  cases  of  epilepsy  and  idiocy  can  be  traced  to  a  probable  hemor- 
rhage in  the  brain  occurring  during  or  after  a  prolonged  or  an  instrumental  labor. 
In  other  and  rare  cases  recovery  is  to  all  appearances  complete.  Treatment :  In 
view  of  the  fact  that  prolonged  labor  is  responsible  for  the  majority  of  cases,  the 
indications  for  treatment  are  almost  wholly  preventive.  Impacted  infants  should 
be  delivered  with  all  possible  despatch.  Forceps  and  other  operative  measures 
must  be  employed  with  judgment,  brain  pressure  being  avoided  as  much  as  pos- 
sible, remembering  that  during  the  progress  of  labor  a  child  about  to  be  bom  is 
made  up  of  a  mass  of  delicate  organs  and  tissues  incapable  of  resisting  unneces- 
sary force.  Asphyxia  demands  immediate  and  persistent  efforts  to  inflate  the 
lungs  fully. 

2.  Injuries  to  Nerve-trunks. — (a)  Facial  Paralysis. — Traumatic  facial  par- 
alysis is  usually  due  to  compression  of  the  nerve  by  the  forceps  at  or  near  the 
stylomastoid  foramen,  but  may  sometimes  occur  in  spontaneous  delivery  (Fig. 
1 019).  In  forceps  accidents  only  one  or  more  of  the  branches  of  the  nerve  may  be 
injured,  so  that  only  a  portion  of  the  distribution  of  the  nerve  may  be  paralyzed 
(most  frequently  the  temporo facial  branch).  Forceps  paralysis  is  chiefly  uni- 
lateral, because  only  one  side  of  the  face  is  exposed  to  the  instrument.  Sponta- 
neous facial  paralysis  :  The  subject  of  forceps  paralysis  is  a  relatively  simple  one, 
but  it  is  otherwise  with  the  facial  paralysis  of  spontaneous  delivery.     This  acci- 


AFFECTIONS-  WHICH   ORIGINATE   INTRA    PARTUM. 


825 


dent  is  of  rare  occurrence,  and  not  more  than  a  dozen  cases  were  upon  record  up 
to  the  year  igoo.     These  cases  have  been  collected  and  analyzed  by  Vogel.* 

Etiology. — This  is  either  traumatic  or 
sponiaueoiis  in  origin.  The  former  is  due 
to  compression  with  forceps  and  is  usu- 
ally unilateral,  and  limited  to  certain 
portions  of  the  nerve-distribution,  most 
frequently  the  temporo-facial  branch. 
The    spontaneous    type    is   much  more 


Fig.  1019. — Facial  Paralysis  OF  THE  Newly       Fig.     1020. — Facial    Paralysis    Due    to 
Born.  Pressure  of  a  Forceps  Blade. —  (Ahl- 

feld.) 


Fig.  1021. — Depression  in  Left  Parietal         Fig.  1022. — Traumatic  Depression  of  the 
Bone  Right  Parietal  Bone. — (Ahlfeld.) 


complex.     Recorded  cases  are  few  in  number,  and  the  mechanism  appears  to  var}' 
greatly.     In  the  absence  of  any  definite  type  every  case  has  an  atypical  character. 

*  "  Monatschrift  f.  Geburtshulfe  und  Gynakologie,"  vol    xii. 


826  THE  PATHOLOGY  OF  THE  NEWLY   BORN. 

Contracted  pelvis  seems  to  be  a  factor  of  importance.  Any  clear  evidences  of 
compression  or  stretching  seem  to  be  wanting. 

Symptoms. — Facial  paralysis  may  be  apparent  at  birth  or  within  the  few 
days  following.  It  has  no  tendency  to  become  worse.  During  repose  the  only 
symptom  in  evidence  may  be  the  open  eye  of  the  affected  side, — due  to  paral- 
ysis of  the  orbicularis.  When  the  child  cries,  the  mouth  is  drawn  to  the  af- 
fected side. 

Diagnosis. — This  is  self-evident,  save  that  a  similar  monoplegia  might  pos- 
sibly be  due  to  an  intracranial  lesion. 

Prognosis. — This  is  essentially  benign;  only  in  a  few  known  cases  has  the 
injury  been  so  severe  that  recovery  was  impossible. 

Treatment. — The  eyeball,  if  exposed,  must  be  protected.  If  spontaneous 
improvement  is  in  evidence  after  the  tenth  day,  the  case  may  be  left  to  itself. 
If  no  improvement  sets  in,  or  if  progress  is  stationary,  faradism  should  be 
employed,  followed,  if  necessary,  by  galvanism.  This  latter  may  be  continued 
for  months  if  the  reaction  of  degeneration  does  not  appear. 

(6)  Brachial  Birth  Palsy. — This  subject  belongs  principally  to  neurology 
and  orthopedics,  because  the  nature  and  extent  of  the  pathological  state  are 
seldom  in  evidence  during  the  lying-in  period.  In  recent  years  the  condition 
has  assumed  considerable  importance,  and  the  older  views  are  undergoing 
marked  changes.  To  those  interested  in  the  details,  I  recommend  especially 
the  monographic  study  of  Clark,  Taylor  and  Prout,*  and  an  article  by  J.  J. 
Thomas. t  In  the  present  connection  I  shall  consider  the  subject  only  as  it 
concerns  the  obstetrician. 

Definition. — Paralysis  involving  the  muscles  of  the  upper  extremity  depend- 
ing upon  injury  to  the  brachial  plexus  during  delivery. 

Frequency. — This  cannot  be  determined,  because  of  our  ignorance  of  the 
state  of  the  brachial  plexus  in  the  still-born  and  in  infants  who  succumb 
soon  after  delivery.  Further,  very  mild  and  transitory  cases  in  survivors 
may  pass  unnoticed.  The  absolute  frequency  in  surviving  infants  has  been 
computed  at  i :  2000. 

Varieties. — The  numerous  varieties  of  palsy  described  by  neurologists  are 
naturally  not  much  in  evidence  during  the  lying-in  period.  It  is  enough  to 
state  that  while  usually  unilateral,  both  sides  may  be  involved.  A  small  pro- 
portion of  cases  are  mild  and  self-limited.  Very  exceptionally  cord  lesions  may 
coexist,  with  paralysis  of  the  lower  extremities.  If  the  first  dorsal  nerve  is  in- 
volved, we  may  see  pupillary  phenomena. 

Etiology  and  Mechanism. — The  injury  to  the  plexus  which  causes  the  paral- 
ysis may  come  about  in  various  ways.  We  have  to  consider  in  this  connection, 
not  only  the  character  of  the  lesion,  but  the  type  of  delivery  through  which  the 
latter  is  caused.  While  a  certain  number  of  cases  may  be  due  to  mere  compres- 
sion, such  as  may  arise  in  connection  with  simple  disproportion,  the  hooked 
finger  in  the  axilla,  forceps-pressure  and  fracture,  dislocation  and  diastasis  of  bony 
structures,  the  great  majority  must  be  due  to  a  stretching  or  tearing  of  the  roots 
of  the  brachial  plexus,  the  latter  mechanism  (laceration)  being  responsible  for 
most  of  the  graver  cases.  Conditions  favoring  laceration  are  encountered  in 
head  presentations  with  rotation  or  traction  by  forceps,  and  in  attempts  to  ex- 
tract the  shoulders;  also — in  about  equal  proportion — in  extraction  of  breech- 
cases  under  all  conditions.  A  small  proportion  of  cases  occur  in  spontaneous 
head  delivery.  Experiments  on  the  cadaver  show  that  the  fifth  cervical  root  is 
the  first  to  give  way  in  stretching,  and  it  is  probable  that  when  this  root  is  alone 

*  "Am.  Jour.  Med.  Sci.,"  Oct.,  1905.  f  "  Boston  Med.  and  Surg.  Jour.,"  Oct.  19,  1905. 


AFFECTIONS 'WHICH  ORIGINATE  INTRA   PARTUM.  827 

involved,  the  case  is  a  relatively  mild  one.  AVith  progressive  increase  in  traction 
the  sixth,  seventh,  and  eighth  roots  become  involved. 

Pathology. — Actual  lesions  are  in  plain  evidence  only  when  a  nerve-root  is 
lacerated,  either  completely  or  in  part.  The  neurilemma  is  the  first  structure 
to  yield  and  doubtless  the  sole  one  in  some  cases.  A  hemorrhage  is  bound  to 
follow,  so  that  in  any  actual  lesion  a  hematoma  must  result,  although  in  mild 
cases  it  may  be  slight  and  quickly  absorbed.  As  a  rule,  the  cicatrix  left  by  organ- 
ization of  the  clot  is  able  to  compress  the  nerve-trunk  and  prevent  regeneration 
in  nerves  torn  through,  as  well  as  cause  traumatic  neuritis  in  trunks  not  actually 
severed. 

Symptoms  and  Diagnosis. — These  vary  greatly  with  the  degree  of  injury  and 
are  characteristic  only  for  high  degrees.  In  typical  cases,  these  being  of  upper 
arm  type,  the  attitude  is  characteristic.  There  is  palsy  of  the  deltoid  and 
supraspinatus,  so  that  the  arm  hangs  powerless  by  the  side;  the  forearm  is  in 
extension  (paralysis  of  flexors)  and  the  hand  in  extreme  pronation  (paralysis  of 
supinator  brevis  and  biceps),  and  the  whole  arm  so  rotated  inward  that  the 
palm  looks  backward  and  outward  (paralysis  of  the  supraspinatus,  infraspinatus, 
and  teres  minor).  Aside  from  the  clinical  picture,  there  often  develop  later 
evidences  of  traumatic  neuritis  due  to  compression  of  the  organizing  blood-clot. 
The  limb  is  tender  and  irritable  on  handling,  and  the  child  peevish  and  fretful. 
As  these  evidences  of  neuritis  are  certain  to  be  followed  by  more  or  less  secon- 
dary palsy,  absence  of  them  is  a  favorable  sign.  In  the  more  severe  cases  some 
of  the  antagonist  muscles  undergo  more  or  less  contracture,  increasing  the  de- 
formity due  to  atrophy  of  the  disused  paralyzed  muscles. 

Prognosis. — If  the  condition  is  due  exceptionally  to  compression  or  very  mild 
laceration,  spontaneous  recovery  may  ensue  in  from  three  to  nine  months,  although 
the  limb  may  never  attain  its  natural  development  and  usefulness.  In  higher 
degress  of  laceration,  the  prognosis  depends  on  the  size  of  the  clot  and  its 
influence  upon  the  continuity  of  the  nerve.  The  limits  vary  between  relative 
recovery  and  total  paralysis.  If  well-defined  traumatic  neuritis  of  the  nerve- 
roots  develops,  the  prognosis  is  much  worse,  and  the  same  is  true  if  the  deep 
cervical  fascia  is  injured  and  must  undergo  repair. 

In  general,  considering  all  cases,  the  prognosis  is  unfavorable — about  one  re- 
covery in  four  cases. 

Treatment. — Palliative  treatment  should  always  be  undertaken  on  account 
of  the  uncertainty  of  the  outcome,  for  delayed  spontaneous  recover}^  is  not  out 
of  the  question.  Here  massage,  hot  and  cold  douches,  passive  motion,  and 
electricity  come  into  play,  as  well  as  orthopedic  devices,  for  all  these  measures 
tend  to  overcome  contractures  and  the  like.  But  if  there  be  marked  evidence 
of  traumatic  neuritis,  complete  immobilization  is  indicated  until  all  evidences  of 
inflammation  have  subsided.  The  extremity  should  be  immobilized  in  the 
natural  position,  which  overcomes  the  tendency  to  contracture  of  the  great  pec- 
toral. After  subsidence  of  the  neuritis,  active  measures  may  be  employed. 
Electricity  not  only  maintains  muscular  tonus,  but  is  said  by  Bethe  to  promote 
nerve  regeneration. 

Radical  treatment  may  be  undertaken  whenever  palliative  measures  seem  to 
have  accomplished  their  limit  of  good.  This  period  varies  from  three  months 
to  a  year.  Apparently  nothing  is  lost  by  waiting  for  the  latter  period,  although 
good  results  may  be  "obtained  at  a  much  "earlier  date.  A  compromise  may  be 
obtained  in  cases  which  show  no  improvement  under  medical  measures  by  the 
fourth  to  sixth  month. 

Whenever  it  appears  that  the  obstacle  to  recovery  is  a  cicatrix  involving  nerve- 


828 


THE  PATHOLOGY   OF   THE   NEWLY  BORN. 


continuity,  an  operation  is  indicated.  In  certain  cases  simple  neurolysis  should 
suffice;  but  as  a  matter  of  fact  there  is  generally  a  separation  of  the  nerve- 
segments  which  requires  suture  of  the  divided  ends.  This  treatment  will  at 
least  prevent  many  of  the  sequelae  of  neglected  cases  of  paralysis,  even  if  it  does 
not  conduce  to  restoration  of  function. 

3.  Injuries  to  the  Cranial  Bones. — These  comprise  (a)  depressions,  (6)  frac- 
tures. 

(a)  Depressions  or  Indentations. — The  occurrence  of  depressions  or 
indentations  in  the  fetal  cranial  bones  does  not  imply  the  existence  of  a  de- 
pressed fracture,  although  the  latter  might  also  be  present.  These  lesions  are 
very  infrequent  occurrences — according  to  Ahlfeld,  not  over  once  in  three  hun- 
dred living  births.  Etiology:  They  are  due  to  some  disproportion  between  the 
fetal  cranium  and  the  maternal  pelvis  when  the  latter  is  contracted,  the  im- 
pression being  made  by  the  sacral  promontory,  for  example;  or  to  the  forceps, 
or  even  to  the  finger  of  the  accoucheur. 
These  impressions  have  usually  the 
dimensions  of  the  imprint  of  a  man's 
thumb  in  wax  (Fig.    1023).     They  are  .^BF'  "''^''  \ 


Fig.  1023. — Depression  in  the  Right  Pari- 
etal Bone  Caused  by  the  Faulty  Appli- 
cation OF  THE  Forceps. — {Author's  collec- 
tion of  fetal  skulls.) 


Fig.  1024. — Contusion  and  Sloughing 
OF  THE  Scalp  Caused  by  a  Contracted 
V-E-LWis.— {Ahlfeld.) 


chiefly  encountered  in  children  bom  alive  and  the  latter  generally  survive.  Prog- 
nosis: The  lesion  is  quite  likely  to  rectify  itself  spontaneously,  either  wholly  or  in 
part,  but  in  case  it  persists  through  life  it  has  seldom  been  known  to  give  rise  to 
any  intracranial  mischief.  Treatment:  It  has  been  proposed  to  trephine  in  cases 
in  which  paralysis  appears  to  be  due  to  this  injury.  I  have  seen  good  results  in 
one  case.  With  this  possible  exception,  there  is  hardly  any  treatment  for  im- 
pressions of  the  skull.  It  is  claimed  that  the  application  of  dry  cups  is  sufficient 
to  correct  the  deformity,  which,  however,  had  better  be  left  to  itself. 

(6)  Fractures. — These  have  also  been  noted  after  both  spontaneous  and 
artificially  aided  delivery  under  the  same  circumstances  which  give  rise  to 
indentations,  although  cases  have  been  placed  on  record  in  which  both  the 
pelvis  and  the  fetus,  were  quite  normal,  and  the  only  possible  source  of  violence 
was  the  uterine  contraction,  possibly  excited  by  the  use  of  ergot.  The 
parietal  is  said  to  be  the  bone  most  frequently  fractured,  but  this  was  not  the 


AFFECTIONS  -WHICH  ORIGINATE  INTRA   PARTUM. 


829 


case  in  the  statistics  collected  by  Lomer.  Any  one  of  the  cranial  bones  may 
be  involved.  Rupture  of  the  sutures  and  detachment  of  some  one  of  the  bones 
may  take  place  under  the  same  circumstances.  If  fracture  of  a  bone  or  rupture 
of  a  suture  should  be  complicated  by  the  laceration  of  a  sinus  or  large  blood- 
vessel, fatal  hemorrhage  will  result.  Minor  degrees  of  hemorrhage  from  rupture 
of  small  vessels  or  some  lesion  of  the  substance  of  the  brain  may  also  complicate 
these  fractures.  As  in  the  case  of  trauma  of  the  bones  of  the  adult  skull,  we  must 
bear  in  mind  the  possibility  of  remote  consequences. 

Facial  Bones. — Fracture  of  the  bones  which  make  up  the  orbit  is  of  occasional 
occurrence,  as  are  likewise  fractures  of  the  lower  jaw  and  diastasis  of  its  sym- 
physis. Fracture  into  the  orbit — usually  through  the  frontal  bone — is  followed 
by  exophthalmus,  yet  this  latter  phenomenon  has  also  been  noted  after  simple 
application  of  the  forceps  over  the  temporal  region  without  the  production  of 
trauma.  Rupture  of  the  bulbus  oculi  and  other  intraorbital  lesions  may  compli- 
cate fracture  into  the  orbit.  While  the  latter  form  of  injury  is  ascribed  chiefly 
to  the  use  of  forceps,  all  the  phenomena  thus 
produced,  including  rupture  of  the  globe,  have 
been  noted  in  spontaneous  delivery ;  while,  on 
the  other  hand,  experimental  fracture  on  the 
cadaver  into  the  orbital  cavity  by  means  of  the 
application  of  forceps  I  have  found  to  be  an 
impossibility.    It  is  therefore  evident  that  the 


Blood  between 
Per/oitcum   anJ  Bone 


Skin 
Subcutaneous  Tissue 
Penostcum 
Bone 


DURA 

SEROUS  INFILlRATlbN    BONE 


PERIOSTEUM 


Fig    1025. — Caput  Succedaneum. 


Fig.   1026. — Cephalhematoma. 


rationale  of  these  orbital  injuries  is  not  wholly  clear.  Fractures  of  the  lower  jaw 
occur,  as  a  rule,  from  traction  on  the  after-coming  head  in  breech  presentations. 

4.  Fractures  of  the  Long  Bones. — As  a  rule,  the  violence  exerted  in  connec- 
tion with  dystocia  and  its  management  tends  to  produce  diastasis  rather  than 
fracture,  provided  that  the  long  bones  of  the  fetus  are  healthy.  When  for  any 
reason  (fetal  rickets)  these  structures  are  brittle,  very  slight  manipulation  may 
produce  a  fracture.  But  Ballantyne  records  the  case  of  a  fracture  of  the  shaft 
of  the  thigh  in  a  healthy  child  during  normal  delivery.  There  were  no  evidences 
of  fetal  rickets  or  prematurity.  Apparently  spontaneous  fractures,  whether  in 
the  healthy  or  otherwise,  cannot  justly  be  put  down  as  examples  of  birth- 
trauma.     If  recognized,  fractures  and  diastases  may  readily  be  healed. 

Dislocations. — The  luxations  which  are  occasionally  present  at  birth  are 
believed  to  be  due  in  most  instances  to  malformations  of  the  joints.  (See 
Congenital  Dislocation  of  the  Hip.)  The  possibility  of  arrested  development 
of  the  joint  in  these  cases  tends  to  invalidate  the  notion  that  luxation  occurs 
as  a  pure  birth  traumatism,  despite  its  general  plausibility. 


830 


THE  PATHOLOGY   OF   THE  NEWLY   BORN. 


5.  Injuries  to  the  Scalp. — Among  those  I  include  (i)  the  caput  succedaneum 
and  (2)  cephalhematoma. 

(i)  Caput  Succedaneum. — The  caput  succedaneum,  otherwise  known  as 
"false  cephalhematoma,"  occurs  with  such  frequency  as  to  be  almost  physiologi- 
cal, the  location  varying  with  the  position  of  the  child's  head  during  delivery. 
This  condition  is  a  phenomenon  of  labor  itself  as  well  as  an  affection  of  the 
newly  bom  child,  and  is  a  subcutaneous,  serous  infiltration  of  that  portion  of 
the  presenting  part  corresponding  to  the  center  of  the  birth  canal  (Fig.  1025). 
As  the  presenting  part  is  forced  through  the  os  uteri  or  the  vulva,  it  escapes 

the  compression  to  which  the  surrounding 
tissues  are. being  subjected,  with  the  result 
that  in  this  free  area  a  sero-sanguineous  effu- 
sion occurs,  since  the  constriction  about  the 
presenting  part  interferes  with  the  circulation. 
As  a  rule,  this  swelling  does  not  form  until 
after  the  membranes  have  been  ruptured  and 
frequently  it  may  not  form  at  all,  as  in  cases 
in  which  delivery  occurs  very  rapidly,  or  if  the 
maternal  parts  are  disproportionately  large. 
While  a  certain  amount  of  blood  is  present  in 
the  effused  liquid,  actual  hemorrhage  is  rare. 
The  caput  succedaneum  varies  considerably  in 
size  and  shape.  It  may  be  rounded,  oval,  or 
elongated,  and  varies  in  its  long  diameter  from 
less  than  one  inch  (2.54  cm.)  up  to  three  inches 
(7.62  cm.).  The  skin  over  the  caput  is  con- 
gested, and  if  the  labor  has  been  unusually 
long,  it  may  present  a  purplish  hue.  As  the 
presenting  part  must  traverse  several  obsta- 
cles to  its  egress,  the  caput  succedaneum  may 
be  formed  within  the  uterus,  within  the  pelvic 
canal,  or  at  the  vulval  orifice,  and  it  is  not 
uncommon  for  a  primary  swelling  to  develop 
when  the  head  passes  the  os  and  a  secondary 
caput  to  form  concentrically  at  a  point  farther 
down,  especially  at  the  vulval  orifice.  If  there 
is  narrowing  within  the  resisting  bony  canal  of 
the  pelvis,  the  caput  may  be  of  extreme  di- 
mensions and  may  be  bom  before  the  head  has 
traversed  the  superior  strait.  (Compare  Ver- 
tex, Part  IV,  and  Face,  Breech,  and  Shoulder 
Presentations,  Part  V.) 

(2)  Cephalhematoma. — In  this  affection 
the  escape  of  blood  is  between  the  periosteum  and  bone,  while  in  caput  succeda- 
neum the  site  of  the  effusion  is  subcutaneous.  The  extravasated  liquid  consists 
wholly  of  blood  (Fig.  1026).  Site:  The  swelling  is  usually  over  a  parietal  bone 
and  limited  by  some  of  the  sutures.  Occasionally  it  transgresses  the  sagittal  suture 
and  lies  over  both  parietals.  The  right  side  of  the  head  is  the  more  commonly 
affected.  Location  of  the  tumor  over  the  other  cranial  bones  occurs  infrequently. 
Symptoms:  Cephalhematoma  is  seldom  present  at  birth  but  appears  two  or  three 
days  later.  The  overlying  skin  is  not  discolored.  The  tumor  may  be  of  any  size 
up  to  that  of  an  apple.     Fluctuation  is  present;  the  limitation  of  the  mass  by 


Fig.  1027. — Caput  Succedaneum  of 
Left  Parietal  Bone  Seen  from 
Behind.  Note  also  the  lateral  flex- 
ion of  the  fetal  body.  Compare  Fig. 
573. — (From  Dr.  W.  E.  Studdiford' s 
frozen  section  at  the  Emergency  Hos- 
pital.) 


AFFECTIONS   WniCH   ORIGINATE  INTRA    PARTUM.  831 

sutures  gives  it  a  bony  outline.  This  affection  must  not  be  confounded  with 
traumatic  hemorrhage  in  the  same  locality  which  occurs  occasionally  as  a  result 
of  forceps  delivery.  Here  the  swelling  is  diffuse  and  is  not  limited  by  the  sut- 
ures. Frequency:  The  frequency  with  which  cephalhematoma  occurs  is  about 
once  in  two  hundred  labors.  Course:  The  cause  of  this  affection  is  obscure  and 
the  factors  which  obtain  in  caput  succedaneum  are  not  in  evidence  here.  It  has 
even  been  found  in  breech  presentations.  The  course  is,  on  the  whole,  benign, 
and  the  tendency  is  to  self-limitation.  The  swelling  usually  persists  for  a  month 
or  more.  Occasionally  infection  of  the  blood-clots  occurs  and  perhaps  caries  of 
the  bone.  Diagnosis:  Cephalhematoma  appears  several  days  after  birth  as  a 
bloody  tumor  underneath  the  pericranium,  generally  on  the  side  of  the  head,  and, 
as  a  rule,  is  due  to  pressure.  Caput  succedaneum  is  present  at  birth  as  a  serous 
infiltration  in  the  tissues  over  the  pericranium  and  over  the  presenting  part  and 
is  due  to  lack  of  pressure.  It  is  soft  but  does  not  fluctuate.  Cephalhema- 
toma has  a  soft,  cystic  feel,  but  later  becomes  crepitant.  It  exists  for  one  or 
two  weeks  and  sometimes  breaks  down  and  suppurates.     Caput  succedaneum 


Fig.  1028. — Single  Cephalhematoma.  Fig.    1029. — Triple  Cephalhematoma. 

{Author's  case  at  Manhattan  Maternity.)  (Author's  case  at  Manhattan  Maternity.) 

lasts  only  two  or  three  days,  after  which  it  disappears.  Besides  these  two 
forms  of  tumor  found  on  the  head  of  the  newly  bom  child  several  others  may 
be  mentioned,  the  possibility  of  the  existence  of  which  at  times  complicates 
the  diagnosis,  viz. :  hemiae  cerebri,  vascular  tumors,  meningocele,  encephalo- 
cele,  and  hydrencephalocele.  These  abnormalities  have  been  noted  elsewhere. 
(See  page  265.)  Meningocele  consists  of  a  tumor  of  the  scalp  partly  formed 
by  the  meninges;  encephalocele  is  made  up  partly  of  brain  substance;  while 
hydrencephalocele  contains  in  addition  a  little  liquid.  (See  page  265.)  Treat- 
ment: Absorption  of  the  extravasated  blood  may  be  hastened  by  the  use  locally 
of  iodine,  and  by  compression.  It  is  not  advisable  to  open  the  cavity  unless 
an  abscess  forms.  The  blood  might  possibly  be  aspirated  to  relieve  the  dangerous 
tension  of  the  scalp  and  pressure  on  the  skull.  In  many  cephalhematomata 
seen  in  hospital  and  private  practice,  in  only  one  was  an  incision  demanded;  in 
this  case,  in  private  practice,  a  child  of  a  primipara  with  a  generally  contracted 
pelvis  after  a  thirty-six-hour  labor  and  a  difficult  forceps  extraction  developed  an 
enormous  blood  tumor.     The  tumor  showed  signs  of  sloughing  and  was  freely 


832  THE  PATHOLOGY   OF   THE  NEWLY   BORN. 

incised,  the  fluid  blood  washed  out  with    saHne   solution,  and  a  gauze   drain 
inserted.     A  rather  tedious  recovery  resulted. 

6.  Hematoma  of  the  Stemomastoid  ;  Caput  Obstipum. — Traumatic  hemor- 
rhage intra  partum  into  the  substance  of  the  stemomastoid  of  one  or  both  sides 
has  been  noted  in  connection  with  both  forceps  and  breech  deliveries  and  after 
over- rotation.  The  extravasated  blood  sets  up  a  myositis,  and  in  time  the 
phenomenon  known  as  wryneck  or  caput  obstipum  may  result.  This  hypothesis 
as  to  the  origin  of  the  deformity,  however,  is  repudiated  by  many,  but  there  is 
no  doubt  that  the  patient  may  have  a  transitory  wryneck.  The  blood  is  ab- 
sorbed in  the  course  of  several  months,  and  in  many  cases  is  known  to  leave 
no  deformity  behind.  This  lesion  may  readily  be  mistaken  for  an  enlarged 
lymph-node,  being  most  commonly  about  the  size  and  shape  of  a  pigeon's 
egg.     No  treatment  is  required,  least  of  all  surgical  intervention. 

7.  Aspiration  Pneumonia. — The  records  of  autopsies  upon  the  newly  bom 
appear  to  show  that  a  certain  number  of  deaths  are  due  to  catarrhal  pneumonia 
which  develops  within  two  days  after  delivery.  There  is  no  evidence  to  show 
that  this  condition  can  originate  ante  partum,  nor  that  it  ever  arises  from  atelec- 
tasis or  infection.  On  the  other  hand,  there  is  little  doubt  that  it  is  due  to  no 
other  cause  than  the  irritating  effects  of  aspirated  amniotic  fluid  which  was 
sterile  at  the  time  of  the  accident.  This  aspiration  indicates  that  the  fetus 
has  attempted  to  respire  in  utero  during  the  act  of  labor  as  a  result  of  temporary 
oxygen  hunger.  The  aspirated  fluids  do  not  appear  to  produce  the  pneumonic 
state  at  the  time  of  occurrence,  for  the  child  is  usually  healthy  at  birth,  and 
perhaps  for  some  time  afterward.  The  supervention  of  the  disease  is  then 
announced  by  rapid  respiration,  cyanosis,  fever,  and  cough.  Death  probably 
occurs  as  a  rule,  although  percentages  are  wanting.  It  is  known  that  recovery 
is  possible  and  that  the  child  may  be  free  from  symptoms  in  the  course  of  a 
week  or  ten  days.  Diagnosis:  This  is  attended  with  great  difflculty.  Aspira- 
tion pneumonia  has  not  been  recognized  as  a  clinical  entity  until  recently. 
It  will  be  necessary  to  exclude  a  number  of  other  conditions,  which  would  be 
almost  impossible  without  autopsy.  If  the  child  is  of ,  normal  development, 
without  evidences  of  septic  infection,  and  especially  if  there  is  a  history  of 
dystocia  with  evidences  of  temporary  intra-partum  asphyxia,  the  presence  of 
the  symptoms  just  narrated  will  make  the  diagnosis  of  aspiration  pneumonia 
very  probable.  Treatment:  The  infant,  since  it  cannot  nurse,  must  be  fed  by 
stomach-tube  or  medicine-dropper,  and  must  receive  stimulants.  The  general 
management  corresponds  largely  to  that  of  similar  cases  in  older  children. 


4.  INTRA-PARTUM  INFECTION. 

I.  Ophthalmia  Neonatorum. — This  term  is  applied  to  a  form  of  acute  con- 
junctivitis occurring  in  infants  and  first  manifesting  itself  within  a  period  of 
from  two  to  five  days  of  birth.  It  has  been  customary  to  describe  at  least 
two  varieties  of  the  disease:  (i)  one  of  which,  of  no  great  importance,  may  be 
called  catarrhal,  and  (2)  the  other,  purulent,  fraught  with  the  greatest  danger 
of  serious  injury  to  the  eye,  the  cornea,  and  consequently  to  sight. 

Etiology. — (i)  A  mild  or  a  moderate  catarrhal  ophthalmia  in  an  infant 
may  be  caused  by  any  non-specific  irritant,  such  as  ordinary  vaginal  secretion, 
the  use  of  soap  or  antiseptics,  too  much  exposure  to  strong  light,  and  also  the 
prophylactic  use  of  antiseptics  in  the  conjunctival  sac,  notably  silver  nitrate. 
(2)  The  exciting  cause  of  the  second  variety  of  the  disease  is  infection,  and  infec- 
tion with  the  gonococcus  alone  or  mixed  with  other  pathogenic  micro-organ- 


AFFECTIONS. WHICH  ORIGINATE  INTRA   PARTUM.  833 

isms  which  have  reached  the  eyes,  during  or  immediately  after  parturition, 
from  the  maternal  passages  or  from  the  hands  or  instruments  of  the  physician. 
There  is  now  no  doubt  of  the  causative  relation  of  the  gonococcus,  which  has 
been  proved  by  numerous  experiments  both  by  culture  and  by  inoculation. 
It  is  possible  that  the  infection  sometimes  occurs  when  the  eyes  are  first  washed 
and  not  during  parturition,  and  it  is,  of  course,  possible  to  infect  the  eyes  of 
an  infant  with  the  gonorrheal  virus  in  the  same  ways  that  the  eyes  of  an  adult 
are  infected,  but  this  would  not  be  strictly  ophthalmia  neonatorum  and  might 
occur  at  any  time.  In  the  milder  cases  the  gonococcus  is  not  found  and  the 
condition  must  be  attributed  to  infection  with  other  pyogenic  germs.  The 
proportion  of  cases  in  which  the  gonococcus  is  found  has  been  estimated  at 
about  36  per  cent.  (Bartley). 

Symptoms. — (i)  Catarrhal  ophthalmia  could  be  dismissed  in  a  very  few 
words  were  it  not  for  the  fact  that  many  of  the  specific  cases  are,  in  the  begin- 
ning, deceptively  like  those  belonging  to  the  mild  category,  so  that  it  is  safer 
to  regard  all  with  suspicion  and  treat  them  like  commencing  purulent  cases 
In  those  cases  which  are  really  catarrhal  the  inner  surface  of  the  lids  is  congested 
and  red  and  there  is  a  serous  or  sero-mucous  discharge,  but  the  lids  are  not 
swollen  and  there  is  no  tendency  for  the  symptoms  to  get  worse  rapidly.  Patho- 
logically, the  condition  is  one  of  acute,  non-specific,  catarrhal  inflammation, 
and  it  tends  to  subside  without  causing  structural  change  or  necrosis  in  the 
mucous  membrane.  Bacteria  may  sometimes  be  present,  but  never  the  gonococ- 
cus.    The  symptoms  are  rarely  severe  and  usually  yield  promptly  to  treatment. 

(2)  The  symptoms  of  purulent  ophthalmia  appear,  as  a  rule,  on  the  third 
day  after  birth,  sometimes  a  little  later,  unless  the  infection  has  occurred  after 
delivery,  when  they  appear  at  any  time.  The  first  signs  are  redness  and  oedema 
of  the  lids,  the  latter  increasing  so  much  that  it  becomes  difficult  for  the  nurse 
to  separate  the  lids.  The  conjunctiva  of  the  lids  becomes  very  greatly  swollen 
and  congested,  and  has  a  granular  or  uneven  surface,  due  to  the  great  exudation 
of  inflammatory  products  into  the  loose  connective  tissue.  Very  soon  the  con- 
junctiva of  the  eyeball  itself  is  involved  and  becomes  swollen  in  the  same  way, 
a  condition  called  chemosis,  and  the  cornea  appears  to  be  at  the  bottom  of 
a  cavity  formed  by  the  swollen  edges  of  this  ocular  conjunctiva.  The  discharge 
at  this  stage  is  serous,  or  more  often  sero-sanguinolent.  In  very  severe  cases 
the  exudate  may  be  so  great  that  the  conjunctival  vessels  are  compressed  and 
the  conjunctiva,  instead  of  appearing  red,  looks  grayish  or  yellowish-pink.  A 
very  free  secretion  of  pus  soon  begins  and  the  intense  swelling  and  oedema  may 
diminish  to  a  certain  extent.  The  pus  may  flow  freely  from  the  palpebral 
fissure,  or  the  edges  of  the  lids  may  adhere  to  each  other,  thus  allowing  the 
conjunctival  sac  to  be  ballooned  out  by  the  accumulation  of  the  secretion. 
This  stage  of  the  disease  is  the  most  dangerous  for  the  nurses  and  attendants, 
and  the  condition  just  described  should  be  specially  guarded  against,  since  the 
pus  is  under  considerable  tension  and  may  fly  into  the  faces  of  the  bystanders 
when  it  is  suddenly  released  by  the  partial  or  complete  separation  of  the  lids. 
The  most  serious  complication  which  may  occur  in  the  disease  is  involvement 
of  the  cornea,  more  often  observed  in  adults,  but  still  common  enough  in  infants 
Destruction  of  this  membrane  of  course  means  blindness,  and  it  is  estimated 
that  at  least  20  per  cent,  of  all  the  blindness  in  the  world  is  due  to  involvement 
of  the  cornea  in  this  form  of  ophthalmia.  The  severer  the  infection,  of  course, 
the  greater  the  danger  of  damage  in  this  respect.  The  first  sign  of  impending 
trouble  is  an  appearance  of  dullness  and  cloudiness  of  the  whole  or  a  part  of 
the  corneal  surface.  The  cloudy  patches  soon  become  distinct  gray  areas  of 
53 


834  THE  PATHOLOGY   OF   THE  NEWLY  BORN. 

infiltration  which  later  turn  yellow  and  ulcerate.  The  ulcers  may  perforate 
into  the  anterior  chamber  or  they  may  spread  without  perforation,  the  former 
being  the  course  with  the  best  prognosis.  If  there  is  marginal  infiltration 
around  the  whole  cornea,  the  so-called  annular  abscess  is  very  likely  to  result, 
and  in  that  event  the  cornea  will  be  destroyed,  with  perhaps  pan-op hthalmitis 
later.  This  means  loss  of  the  eye.  In  general,  it  may  be  said  that  the  more 
pronounced  the  chemosis,  the  greater  the  danger  that  the  cornea  will  be  involved 
in  the  infectious  process.  Fortunately  in  infants,  with  proper  measures,  the 
danger  of  serious  damage  is  not  great.  When  the  disease  progresses  favorably, 
the  swelling,  redness,  and  purulent  discharge  gradually  diminish,  and  finally 
the  lids  reach  a  normal  condition,  though  several  weeks  may  be  required  for 
this.  In  infants  there  is  rarely  any  tendency  ior  the  inflammation  to  persist 
and  become  chronic.  A  febrile  movement  is  often  present  and  evidences  of 
systemic  gonococcus  infection  may  occur;  acute  inflammation  of  the  joints  has 
been  observed. 

Diagnosis. — This  should  present  no  difficulties  except  in  the  beginning 
of  the  attack,  and  in  doubtful  cases  it  is  wise  to  be  upon  the  safe  side  and  treat 
the  case  as  one  of  specific  ophthalmia.  The  profuse  purulent  secretion  and 
swelling  of  the  lids  are  characteristic.  The  history  of  the  mother  may  be  of 
assistance,  and  an  attempt  should  be  made  to  confirm  the  diagnosis  by  micro- 
scopic examination  of  both  maternal  and  fetal  secretions. 

Prognosis. — In  a  large  proportion  of  the  cases  that  do  not  receive  prompt  and 
intelligent  treatment  the  sight  is  destroyed.  It  has  been  estimated  before  the 
general  adoption  of  prophylactic  measures  that  from  26  to  30  per  cent,  of 
all  the  cases  of  total  blindness  in  adults  was  the  result  of  purulent  ophthalmia 
of  the  newly  born. 

Treatment. — (i)  Catarrhal:  The  treatment  of  catarrhal  conjunctivitis  con- 
sists in  cleanliness  and  protection  from  light.  A  solution  of  borate  of  sodium, 
ten  grains  to  the  ounce  of  camphor  water,  or  a  solution  of  boric  acid,  may  be 
used  frequently  as  an  eye-wash,  and  it  is  a  good  plan  to  keep  the  edges  of  the 
lids  from  adhering  by  using  a  little  boric-acid  ointment  upon  them.  The  eyelids 
must  be  kept  free  from  dried  secretions  by  some  such  means,  and  it  is  better 
to  make  the  manipulations  at  regular  intervals,  longer  or  shorter  as  the  case 
is  mild  or  severe,  so  that  the  child  will  rest  without  being  interfered  with  need- 
lessly. The  condition  is  one  which,  as  a  rule,  responds  very  promptly  to  treat- 
ment. (2)  Purulent:  The  treatment  of  purulent  ophthalmia  neonatorum  re- 
solves itself  into  two  parts:  namely,  (i)  prophylactic  and  (2)  curative. 

(i)  Prophylaxis. — What  is  as  important  in  this  matter  as  treatment  is  prophy- 
laxis, and  no  measure  should  be  neglected  which  can  assist  in  preventing  the 
occurrence  of  the  disease.  When  the  maternal  passages  are  suspected,  a  pre- 
liminary course  of  antiseptic  treatment  should  be  instituted,  beginning  about 
two  weeks  before  delivery.  This  should  consist  in  daily  or  twice  daily  vaginal 
douching,  first  with  a  mild  alkaline  solution  and  then  with  one  of  bichloride 
of  mercury,  strength  i  :  5000.  Just  before  delivery  something  must  be  done 
to  provide  a  substitute  for  the  normal  lubricating  mucus  which  will  have  been 
washed  away  by  the  douching  process,  and  a  i  per  cent,  lysol  solution  will  be 
found  useful  for  this  purpose.  The  vagina  may  be  washed  out  with  it  when 
labor  begins.  As  soon  as  the  child  is  bom  its  face  must  be  carefully  washed, 
special  attention  being  given  to  the  eyes,  and  even  when  infection  is  not  suspected 
one  or  two  drops  of  a  i  per  cent,  silver-nitrate  solution  should  be  dropped  into 
each  conjunctival  sac.  This  may  be  washed  away  in  a  moment  or  two  with 
salt  solution  if  desired.     It  has  now  become  with  most  obstetricians  in  maternity 


AFFECTIONS -WHICH   ORIGINATE  INTRA   PARTUM.  835 

service  a  matter  of  routine  practice  to  use  this  i  per  cent,  solution  in  the  eyes 
of  all  infants,  and  since  the  method  was  introduced  the  number  of  cases  of 
ophthalmia  neonatorum  has  decreased  enormously.  As  an  illustration,  we 
may  cite  the  experience  of  Crede,  who  suggested  the  method.  At  his  Lying- 
in  Asylum,  at  Leipsic,  before  the  use  of  silver  nitrate,  this  form  of  ophthalmia 
occurred  in  10.8  per  cent,  of  all  infants;  after  the  treatment  was  systematically 
carried  out  the  percentage  fell  to  o.i  or  0.2  per  cent.  Other  similar  experiences 
have  been  reported.  The  methods  of  procedure  will  almost  invariably  cure 
or  protect  the  infant  from  this  infection,  but  we  have  the  further  duty  of  pro- 
tecting nurses,  relatives,  and  physicians.  It  is  hardly  necessary  to  point  out 
the  extremely  infectious  character  of  the  discharge  from  the  eyes  of  a  patient 
with  gonorrheal  ophthalmia  or  to  emphasize  the  importance  of  avoiding  the 
chance  of  infecting  a  clean  eye.  Every  case  should  be  promptly  isolated  and 
placed  under  the  care  of  a  special  nurse.  Attendants  must  be  trained  in  the 
observance  of  antiseptic  precautions,  and  no  detail  must  be  neglected.  Cotton, 
gauze  pads,  and  dressings  should  be  burned  after  use,  and  the  minutest  care 
should  be  exercised  to  keep  members  of  the  family,  especially  children,  away 
from  the  patient  or  anything  which  has  been  used  about  him.  The  patient 
himself  must  also  be  prevented  from  rubbing  his  eyes.  If  a  clean  eye 
should  accidentally  be  brought  in  contact  with  infection,  a  few  drops  of  the  2 
per  cent,  silver-nitrate  solution  should  be  instilled,  after  the  eye  has  been  flushed 
with  boric  solution,  and  then  cold  applications  should  be  made  for  two  or  three 
hours.  After  this  a  boric-acid  wash  should  be  used  occasionally.  The  duration 
of  this  form  of  conjunctivitis  may  be  several  weeks,  and  treatment  must  be 
kept  up  according  to  the  symptoms  as  long  as  they  exist.  If  corneal  infection 
occurs,  it  is  a  good  plan  whenever  possible  to  get  the  assistance  of  an  ophthal- 
mologist, since  there  are  often  many  details  which  can  best  be  handled  by  the 
specialist. 

(2)  Curative. — To  cure  a  patient,  the  sooner  the  disease  is  attacked,  the  better 
is  the  chance  of  prompt  success.  For  at  least  a  century  silver  nitrate  in  solutions 
of  varying  strength  has  been  the  mainstay  in  the  treatment  of  all  forms  of  con- 
junctivitis, and  in  1882  Crede  proposed  its  use  as  a  prophylactic  in  infants.  When 
the  disease  is  already  present,  active  treatment  must  be  at  once  instituted,  and 
what  we  must  depend  upon  chiefly  is  antisepsis  and  local  cold.  The  lids  and  the 
conjunctival  sac  must  be  kept  free  from  accumulated  pus  and  some  kind  of  anti- 
septic must  be  applied  to  their  surfaces.  Often  cold  must  be  applied  continuously 
if  we  are  to  expect  success.  During  the  first  three  or  four  days  before  the  dis- 
charge becomes  purulent,  cold  compresses  must  be  applied  continuously  for  an 
hour  twice  or  three  times  a  day  and  free  washing  of  the  conjunctival  sac  should  be 
done  in  addition  four  or  five  times  a  day  with  a  warm,  saturated  boric-acid  solu- 
tion or  a  I  :  2000  potassium  permanganate  or  a  i  :  10,000  sublimate  solution. 
This  is  of  the  greatest  importance,  and  the  washings  should  be  frequent  enough 
to  keep  the  eyes  clear  of  pus.  An  eye-dropper,  glass  syringe,  or  absorbent 
cotton  dipped  in  the  cleansing  solution  can  conveniently  be  used  (Fig.  1030). 
The  child  on  its  side  should  be  held  on  a  piece  of  rubber  on  a  nurse's  lap 
and  the  lower  eye  gently  irrigated,  the  solution  being  first  used  to  wash 
away  secretion  from  the  outside  of  the  lids,  and  then  gently  from  between  the 
lids,  enough  force  only  being  used  to  wash  away  the  discharge  and  cleanse 
the  conjunctival  surface.  In  addition  to  this,  it  is  a  good  plan  to  instil 
once  a  day  a  few  drops  of  a  10  per  cent,  protargol  solution  (Fig.  628).  It  is 
not  necessary  to  use  silver  nitrate  at  this  stage,  and  mercury  bichloride  will  be 
found  too  irritating  in  solutions  of  sufficient  strength  to  exercise  active  antiseptic 


836 


THE   PATHOLOGY   OF   THE   NEWLY   BORN. 


properties.  If  the  case  under  observation  should,  turn  out  to  be  simply  an 
aggravated  instance  of  catarrhal  ophthalmia,  this  treatment  will  be  found 
sufficient;  but  if  pus  begins  to  form  and  all  the  symptoms  increase,  and  also 
if  the  gonococcus  can  be  demonstrated,  we  must  change  our  treatment  to  some 
extent.  The  conjunctival  sac  must  be  cleansed  much  more  frequently,  at  least 
every  hour  during  the  day,  but  perhaps  not  so  often  at  night,  and  the  lids 
must  be  kept  from  sticking  together  by  the  method  already  described.  The 
protargol  solution  must  be  increased  in  strength  to  20  per  cent,  and  it  may 
be  used  more  frequently,  preferably  after  the  discharge  has  been  thoroughly 
washed  away  and  the  shreds  of  muco-pus  carefully  brushed  from  the  conjunctiva 

with    bits    of    cotton    or 
gauze.     If  the  action  of  the 
protargol  does  not  seem  to 
^i^  be  favorable,  it  will  occa- 

sionally  be  found  advisable 
to  employ  a  2  per  cent,  or 
even  stronger  silver-nitrate 
solution,  but  it  is  better 
under  such  circumstances 
to  make  the  application 
only  to  the  everted  lids  and 
to  wash  the  residue  away 
at  once  with  salt  solution. 
The  extent  of  the  use  of 
cold  applications  depends 
somewhat  upon  the  inten- 
sity of  the  inflammation, 
but  in  all  cases  ranging 
from  severe  to  bad,  this 
must  practically  be  con- 
tinuous. This  involves  un- 
remitting care  on  the  part 
of  the  nurse,  who  will  re- 
quire rather  frequent  relief. 
The  best  method  to  pursue 
is  to  have  a  block  of  ice  in 
the  room  and  to  prepare  a 
number  of  soft  gauze  pads 
about  an  inch  or  an  inch 
and  a  half  in  diameter, 
which  can  be  placed  on  the 
ice  and  thus  allowed  to 
become  moist  and  cold. 
These  can  be  used  as  often  as  necessary  and  must  be  changed  as  soon  as  they 
become  warmed.  Not  infrequently  it  is  necessary  to  place  a  fresh  pad  on  each  eye 
every  minute,  at  the  same  time  that  the  antiseptic  treatment  is  being  kept  up.  In 
cases  of  corneal  involvement  atropin  must  be  used  to  dilate  the  pupil,  and  in  all 
bad  cases  its  use  is  a  wise  precaution.  If  there  seems  to  be  danger  of  strangula- 
tion of  the  corneal  vessels  on  account  of  the  density  of  the  exudate  and  con- 
sequent interference  with  the  nutrition  of  the  cornea,  hot  applications  may  be 
substituted  for  cold  for  a  time  so  as  to  stimulate  the  circulation  and  absorption. 
It  is  also  occasionally  necessary  to  make  radial  incisions  in  the  swollen  con- 


N 


Fig.  1030. — AlETHOD  of  Irrigating  the  Eye  of  the  In- 
fant IN  Cases  of  Ophthalmia  Neonatorum. 


DISEASES  INCIDENT   TO   CHANGE  OF  ENVIRONMENT.        837 

junctiva  in  order  to  relieve  the  external  tension.  It  is  better  not  to  use  the 
stronger  solutions  of  silver  nitrate  and  protargol  more  than  once  a  day.  In 
the  case  of  weak  infants  care  must  be  taken  not  to  disturb  the  child  any  oftener 
than  is  absolutely  necessary,  for  a  certain  amount  of  undisturbed  rest  is  essential 
and  must  be  allowed,  even  if  we  are  not  able  to  cleanse  the  lids  quite  as  often 
as  we  should  otherwise  wish.  The  child  must  be  kept  warm  and  carefully  and 
regularly  fed,  and  any  gastro-intestinal  disturbance  must  receive  prompt  atten- 
tion. In  a  few  very  severe  cases  the  swelling  and  chemosis  may  be  so  great 
that  a  short  incision  may  have  to  be  made  in  order  to  relieve  tension  and  give 
access  to  the  conjunctival  sac.  When  such  measures  are  thought  necessary,  no 
hesitation  need  be  felt  in  calling  upon  the  expert  ophthalmologist  for  assistance. 
Sometimes  a  certain  amount  of  chronic  inflammation  remains  after  the  acute 
symptoms  have  subsided.  This  may  be  treated  by  daily  applications  of  a  i 
per  cent,  protargol  or  a  0.5  per  cent,  zinc  sulphate  solution. 

Expert  Advice. — In  view  of  the  danger  of  loss  of  sight  from  this  disease 
and  the  responsibility  involved,  it  is  always  well  for  the  obstetrician  or  general 
practitioner  to  secure  the  services  of  an  expert  ophthalmologist,  if  possible,  in 
every  case  of  the  purulent  disease. 

2.  Gonorrheal  Stomatitis, — A  gonorrheal  infection  in  infants  has  its  origin 
in  the  genital  tract  of  the  mother,  and  for  that  reason  it  is  confined  almost 
entirely  to  the  newly  bom.  Etiology:  The  delicate  mucous  membrane  of  the 
newly  born  child  offers  little  resistance  to  this  infection,  especially  after  im- 
proper efforts  have  been  made  to  cleanse  the  mouth,  and  any  abrasion  offers 
a  favorable  entrance  for  the  gonococcus.  A  pre-existing  or  concomitant  oph- 
thalmia explains  the  origin  of  many  cases.  Pathology:  The  hyperemia  of  the 
acute  stage  of  inflammation  is  followed  by  the  formation  of  creamy  patches 
upon  the  hard  palate  or  tongue.  But  the  process  is  distinctly  local  and  shows 
no  tendency  to  affect  the  entire  stomal  mucous  membrane.  There  is  a  possi- 
bility, however,  of  an  added  infection  due  to  staphylococci  or  streptococci  result- 
ing in  pathological  conditions  more  serious  in  character.  Symptoms  and  diag- 
nosis: With  stomatitis  of  this  character  alone,  constitutional  symptoms  are 
usually  absent,  and  the  general  health  is  not  particularly  affected.  Microscopic 
examination  of  the  exudate  reveals  the  nature  of  the  exciting  cause.  Treatment: 
A  saturated  solution  of  boric  acid  frequently  applied  is  a  most  efficient  agent. 
In  more  severe  cases  a  mixture  of  boric-acid  solution  and  hydrogen  peroxide 
is  very  useful.     The  solid  stick  of  silver  nitrate  may  also  be  of  service. 


IV.  DISEASES  INCIDENT  TO  CHANGE  OF  ENVIRONMENT. 

I.  Primary  Asphyxia  of  the  Newly  Born.  2.  Atelectasis  Neonatorum,  j.  Failure  of  Cir- 
culation. 4.  (Edema  Neonatorum..  5.  Failure  of  Digestion  and  Assimilation.  Inani- 
tion.    6.  Inanition  Fever. 

The  fetus  at  birth  not  only  changes  its  surroundings  from  an  aqueous  to 
an  aerial  medium,  but  begins  to  use  hitherto  quiescent  organs  and  to  disuse 
others  previously  active.  Naturally  a  healthy  child  should  encounter  little  or 
no  difficulty  in  this  physiological  readjustment;  but  it  is  otherwise  with  the 
premature  or  undeveloped.  Nearly  every  one  of  the  more  important  functions 
may  be  in  abeyance  as  a  result  of  this  congenital  debility.  The  lungs  may  not 
expand,  the  heart's  action  may  fail,  the  stomach  may  be  unable  to  retain  the 
ingesta,  assimilation  may  be  impossible,  etc.  Mere  functional  incapacity  may 
be  associated  with  various   affections  largely  peculiar  to  this  period   of  life, 


838  THE  PATHOLOGY  OF   THE  NEWLY  BORN. 

and  believed  to  be  the  expression  of  incapacity  of  the  fetus  to  adapt  itself 
to  the  external  world.  These  affections  do  not  appear  to  date  from  fetal  life, 
nor  have  they  been  brought  into  connection  with  any  form  of  infection  post 
partum.  They  are  not  hereditary,  and  hence  they  may  be  regarded  as  due 
to  a  "change  of  life,"  just  as  puberty  and  the  climacteric  have  their  own  peculiar 
disorders. 

1.  Primary  Asphyxia  of  the  Newly  Bom. — This  term  is  applied  to  the  following 
condition:  When  an  infant  delivered  without  dystocia,  and  with  no  symptoms 
which  point  to  subaeration  ante  partum  or  intra  partum  (livid  or  pallid  hue, 
anomalies  of  the  circulation,  etc.),  fails  to  respire  as  soon  as  the  cord  is  cut, 
we  have  a  state  entirely  distinct  from  the  ordinary  type  of  asphyxia  which 
accompanies  dystocia.  In  some  instances  these  infants  do  breathe  for  a  short 
time,  or  the  failure  of  respiration  may  not  set  in  until  several  days  have  elapsed. 
This  affection  is  purely  an  anomaly  of  readjustment  of  the  infant  to  its  new 
environment  and  therefore  to  be  met  with,  as  a  rule,  in  weak  and  premature 
infants.  It  should  be  carefully  distinguished  from  conditions  due  to  labor 
itself — for  example,  pneumonia  due  to  aspiration  of  amniotic  fluid;  and  also 
from  the  so-called  spurious  asphyxia  in  which  the  respirations  are  so  shallow 
that  they  pass  unnoticed.  It  must  also  be  borne  in  mind  that  while  many 
cases  of  primary  asphyxia  of  the  newly  bom  are  due  to  simple  failure  of  the 
lungs  to  expand,  others  are  rendered  possible  by  the  presence  of  disease  or 
malformation  of  fetal  origin  (syphilis  of  the  lungs,  hydrothorax,  defects  of  the 
diaphragm,  etc.).  The  mechanism  of  these  cases  is  not  difficult  to  understand. 
Neither  the  lung  tissue  nor  the  parietes  of  the  chest  are  sufficiently  developed 
for  respiration,  and  when  malformations  or  diseases  are  present,  the  mechanical 
hindrance  is  also  capable  of  accounting  for  the  failure  of  respiration.  The 
thorax  of  the  premature  child  may  undergo  rhythmic  movements  (this  is  said 
to  occur  even  in  utero)  without  any  corresponding  inflation  of  the  lung.  For 
all  practical  purposes  the  remainder  of  this  subject  may  be  considered  under 
Prematurity  and  Asphyxia  Intra  Partum. 

2.  Atelectasis. — In  the  healthy  infant  bom  under  favorable  circumstances, 
the  function  of  respiration  is  established  in  the  first  minute  of  life,  a  few  vigorous 
cries  expanding  the  lungs  freely.  In  other  infants,  however,  the  lungs  do  not 
undergo  inflation,  or  only  a  portion  of  the  upper  lobes  is  inflated  while  the 
remainder  of  the  organs  does  not  change  from  the  fetal  state.  This  is  termed 
congenital  atelectasis.  While  atelectasis  may  occur  without  causing  asphyxia, 
and  while  the  latter  may  not  be  due  necessarily  to  inability  of  the  lungs  to  inflate, 
in  the  majority  of  cases  the  two  conditions  must  necessarily  coexist.  The  lungs 
of  a  healthy  infant  expand  as  soon  as  the  cord  is  cut,  but  in  the  weak  or  pre- 
mature a  certain  portion  fails  to  become  aerated.  The  child  may  be  threat- 
ened with  death  from  asphyxia,  and  the  application  of  the  usual  management 
for  that  condition  may  reanimate  it.  The  atelectatic  area,  however,  may  still 
persist  and  threaten  the  child's  life  during  the  ensuing  hours  or  days.  If  the 
newly  bom  has  not  succeeded  in  breathing  at  all  and  has  succumbedfat  once  to 
asphyxia,  the  atelectasis  is  of  course  absolute.  But  if,  as  often  happens,  respir- 
ation has  been  inaugurated  either  spontaneously  or  as  a  result  of  treatment,  some 
of  the  lung  tissue — as  a  rule,  both  upper  lobes — is  not  only  inflated  but  emphy- 
sematous, the  rest  remaining  in  the  fetal  state.  If  the  child  survives,  air  be- 
gins to  enter  the  posterior  aspect  of  the  lower  lobes.  The  central  portion  of  the 
lungs  is  the  last  to  yield.  Despite  the  apparent  solidity  of  the  atelectatic  tissue, 
it  may  readily  be  inflated  artificially  even  months  after  birth.  When  these  chil- 
dren do  not  succumb  at  birth  they  simply  present  the  picture  of  debility  or  pre- 


DISEASES  INCIDENT   TO   CHANGE  OF  ENVIRONMENT.        839 

maturity  and  are  menaced  by  death  in  various  forms  (marasmus,  convulsions, 
etc.).  If  they  are  doomed  to  perish  of  asphyxia  cyanosis  gradually  develops. 
The  prognosis,  however,  is  not  hopeless,  as  many  of  these  children  survive. 

Etiology. — Abnormal  conformations  in  the  respiratory  tract  are  rare,  so  that 
practically  it  may  be  said  that  atelectasis  is  due  primarily  to  feeble  respiration 
following  some  injury  to  the  centers  in  the  brain  from  prolonged  labor  or  in- 
strumental delivery.  Atelectasis  may  occur,  however,  in  infants  whose  respira- 
tions are  apparently  normal  in  rhythm  but  not  sufficiently  full  and  forcible  to 
cause  complete  pulmonary  expansion. 

Pathology. — The  conditions  found  at  autopsy  depend  upon  whether  the 
child  lived  a  few  days  or  longer.  In  the  newly  bom  both  lungs  are  generally 
involved.  The  anterior  borders  of  the  upper  lobes  are  inflated  and  light  pink 
in  color  and  emphysematous  from  the  added  strain  thrown  upon  them;  while 
the  rest  of  the  lung  is  in  the  fetal  state,  dark  brownish  in  color,  not  inflated,  and 
firm  to  the  touch.  In  older  infants  the  posterior  parts  of  the  lower  lobes  are 
found  not  inflated  or  only  superficially  so,  the  central  portion  of  the  lobes  being 
of  no  service  in  the  act  of  respiration.  Incidentally  there  may  be  found  various 
degrees  of  congestion  of  the  liver,  spleen,  stomach,  and  intestines,  due  directly 
to  the  imperfect  pulmonary  circulation. 

Symptoms. — In  infants  with  a  history  of  asphyxia  at  birth  atelectasis  is  most 
noticeable.  They  gain  little  in  weight,  the  circulation  is  poor,  the  extremities  are 
cold,  they  cry  feebly  if  at  all,  and  do  not  take  nourishment  well.  In  some  cases 
death  occurs  in  a  few  days,  while  others  live  for  weeks  and  months.  Cyanosis 
may  develop  at  any  time  and  death  follow  from  asphyxia  or  convulsions.  Many 
infants,  however,  who  begin  life  most  unpromisingly  gain  steadily  under  favor- 
able conditions  and  recover  completely. 

Diagnosis. — The  general  condition  of  the  infant  gives  far  more  information 
than  does  physical  examination  of  the  chest.  Owing  to  the  fact  that  both  lungs 
are  generally  involved,  the  ordinary  advantage  of  comparing  the  two  sides 
of  the  chest  is  lost ;  but  if  it  happens  that  one  lung  only  is  the  seat  of  the 
trouble,  we  may  find  the  respiratory  murmur  feebler-  over  that  portion  of 
the  chest.  Cyanosis  or  convulsions  in  the  very  young  should  always  suggest 
the  possibility  of  atelectasis. 

Treatment. — If  a  vigorous  cry  does  not  occur  spontaneously  at  birth,  the 
use  of  the  hot  and  cold  bath  should  be  resorted  to.  Spanking  is  often  effec- 
tive and  should  be  repeated  at  regular  intervals  if  necessary.  In  those  pre- 
maturely bom  careful  attention  should  be  directed  to  regulating  the  body 
temperature  by  the  use  of  cotton,  hot  baths,  or  an  incubator.  Friction  and 
gentle  massage  are  of  value  in  some  cases.  If  convulsions  or  asphyxia  develop, 
the  hot  bath  offers  the  greatest  hope  of  benefit. 

3.  Failure  of  Circulation. — The  various  malformations  of  the  heart  are  some- 
times of  such  a  degree  that  death  results  in  the  neonatal  period.  In  the  milder 
varieties  the  duration  of  survival  maybe  indefinite.  These  anomalies  give  rise 
to  cyanosis.  Some  debilitated  infants  appear  to  succumb  to  simple  arrest  of  the 
circulation.  The  condition  known  as  oedema  neonatorum  is  probably  associated 
with  a  feeble  right  heart,  with  overfilling  of  the  venous  circulation. 

4.  (Edema  Neonatorum. — The  oedema  appears  in  various  superficial  localities 
and  in  some  cases  general  anasarca  may  develop;  the  serous  cavities,  however, 
are  rarely  involved.  Unless  the  infant  dies  as  a  result  of  disability,  the  oedema 
may  disappear  within  a  few  da3^s.  Relapses  are  frequent.  In  sclerema  neo- 
natorum failure  of  the  circulation  is  one  of  the  most  striking  S3^mptoms,  although 
it  cannot  be  set  down  as  the  cause  of  the  affection. 


840  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 

5.  Failure  of  Digestion  and  Assimilation. — Marasmus  as  ordinarily  described 
is  a  condition  which  develops  after  the  neonatal  period  and  extends  over  a  con- 
siderable period  of  time  (see  page  840).  An  analogous  condition  of  the  newly 
bom,  which,  however,  leads  much  more  rapidly  to  death,  is  generally  known  as 
inanition.  A  peculiar  phenomenon  connected  with  starvation  in  the  newly 
bom  is  a  rise  of  temperature  (hyperpyrexia  neonatorum).  According  to  Holt, 
however,  the  trouble  in  these  cases  may  lie  entirely  with  the  mother,  whose 
breasts  are  dry.  Children  who  are  bom  healthy,  if  they  obtain  no  milk  by  the 
third  or  fourth  day  of  life,  show  the  commencement  of  inanition  by  a  rise 
of  temperature  to  101°  F.  or  upward,  which  subsides  as  soon  as  the  child 
is  fed.  Inanition  which  is  the  fault  of  the  child  may  be  due  to  refusal  of 
the  breast  or  of  food,  or  to  absolute  inability  to  nurse  or  to  retain  the  milk,  or, 
finally,  to  inability  to  digest  and  assimilate  it.  These  causes  are  all  operative 
in  weak  and  premature  infants  at  birth.  Naturally  the  various  phenomena  of 
prematurity  or  debility  coexist,  so  that  it  is  difficult  to  assign  particular  symp- 
toms to  inanition.  The  exhaustion  and  debility  are  accentuated  and  the  child's 
life  is  rapidly  forfeited,  sometimes  in  two  or  three  days.  In  cases  in  which 
some  nourishment  is  taken  gain  in  weight  is  a  good  sign,  and  vomiting  is  a  bad 
one.  The  management  of  these  cases  is  necessarily  included  under  that  of  "  pre- 
maturity "  and  "congenital  debility."  Refusal  of  food  is  met  by  gavage.  If 
vomiting  is  present,  the  milk  thus  given  should  be  diluted  or  an  attempt  should 
be  made  to  find  something  which  the  stomach  will  tolerate.  (Compare  Inan- 
ition, page  840.) 

6.  Inanition  Fever. — It  was  formerly  supposed  that  inanition  fever  did  not 
occur  as  a  distinct  condition,  but  observations  during  the  past  ten  years  prove 
it  to  be  comparatively  frequent,  especially  from  the  second  to  the  fifth  day. 
It  is  really  due  to  starvation,  the  infant  being  unable  to  obtain  the  proper 
amount  of  nourishment  from  the  breast  as  a  result  of  limited  or  negative  supply 
of  milk,  of  depressed  nipples,  or  of  inflammatory  conditions.  It  is  not  confined 
to  premature  or  delicate  infants,  but  occurs  quite  as  frequently  in  those  ordi- 
narily vigorous.  Fever  is  the  most  important  symptom;  it  ranges  from  102°  to 
105°  F.,  and  generally  reaches  its  highest  point  on  the  third  or  fourth  day  of  life. 
The  infants  lose  weight  rapidly,  not  infrequently  eight  ounces  in  twenty-four 
hours,  and  the  condition  is  one  that  quickly  causes  alarm.  Various  other  symp- 
toms accompany  the  fever  and  loss  of  weight.  A  certain  number  of  cases  are  fret- 
ful and  restless,  while  others  show  hot,  dry  skin,  extreme  irritability,  and  much 
prostration.  When  all  other  causes  of  fever  can  be  excluded,  and  investigation 
proves  that  the  proper  amount  of  nourishment  has  not  been  taken  by  the  infant, 
the  case  may  be  called  ' '  inanition  fever. ' '  "  Treatment  consists  in  the  administra- 
tion of  water  at  regular  intervals  until  thirst  is  alleviated  and  the  temperature 
falls.     If  necessary,  a  wet-nurse  should  be  secured  or  artificial  feeding  begun. 


V.  DISEASES  DUE  TO   BACTERIA  AND  FUNGI. 

I  Umbilical  Sepsis.  2.  Septic  Coryza.  j.  Septic  Pneumonia.  4.  G astro-intestinal  Sepsis. 
(i)  Ulcerative  Stomatitis.  (2)  Gangrenous  Stomatitis,  (j)  Parotitis.  (4)  Retropharyn- 
geal Abscess.  (5)  Gastro-enteritis.  5.  Cutaneous  Sepsis.  (/)  Dermatitis  ex-foliaiiva 
neonatorum  (Ritter's  Disease).  (2)  Pemphigus  acutus  neonatorum.  Septic  Pemphigus. 
(^1  Impetigo  contagiosa  neonatorum  (Periumbilical  Pemphigus) .  {4)  Ecthyma  neonatorum. 
(5)    Multiple  Abscess.      (6)   Erysipelas.     6.   Tetanus.     7.  Aphthce.     8.   Thrush. 

The  newly  bom  infant  may  be  attacked  by  the  omnipresent  pathogenic  bac- 
teria, which  may  cause  infection  at  the  navel,  in  the  mouth,  or  the  gastro-enteric 


DISEASES  DUE   TO   BACTERIA   AND   FUNGI.  841 

tract,  etc.;  also  by  fungi.  The  principal  members  of  this  group  are  sepsis  in  its 
manifold  aspects,  trismus,  aphthae,  etc.  The  bacteria  which  are  pathogenic  to  the 
newly  born  include  the  ordinary  exciters  of  suppuration  (streptococci  and  staphy- 
lococci), the  germs  of  tetanus  and  erysipelas,  and  to  a  certain  extent  any  virulent 
micro-organism  which  may  cause  chance  infection.  The  newly  born  enjoys  a 
relative  immunity  from  many  infectious  diseases,  and,  generally  speaking,  only 
those  bacteria  need  be  discussed  which  show  a  particular  tendency  to  attack 
the  infant  as  it  emerges  into  the  world.  The  gonococcus,  since  it  menaces  the 
unborn  child,  is  placed  among  the  causes  of  intra-partum  diseases.  Of  fungi 
which  tend  especially  to  attack  the  newly  bom,  it  will  be  sufficient  to  mention 
those  which  cause  aphthous  stomatitis  and  thrush. 

Septic  Infection. — General  Remarks. — By  septic  infection  in  the  newly  born 
must  be  understood  a  systemic  disease  which  takes  the  form  of  an  extremely 
severe  infectious  process,  begins  usually  at  the  navel,  and  later  involves  in  a 
greater  or  less  degree  other  parts  of  the  body.  It  is  one  of  the  most  dreaded 
affections  of  early  life. 

Frequency. — When  proper  aseptic  and  antiseptic  precautions  enter  into  the 
details  of  delivery  and  care  of  the  newly  born,  few  cases  of  septic  infection  follow. 
The  great  majority  of  cases  are  referred  to  influences  which  seem  to  be  present 
and  to  flourish  at  intervals  in  lying-in  hospitals  or  wherever  puerperal  infection 
finds  a  harbor.  It  naturally  is  more  common  in  those  localities  and  among 
those  people  who  do  not  enjoy  the  blessings  of  modem  obstetrical  attendance, 
though  it  has  also  its  victims  among  the  best  classes  of  society. 

Pathology. — In  eight  cases  out  of  ten  the  process  begins  in  the  umbilical 
vessels  or  in  the  connective  tissue  about  the  navel;  the  blood-clots  in  the  vessels 
and  the  clean-cut  edges  of  the  stump  offering  good  soil  for  bacterial  development. 
Injuries  or  abrasions  of  the  skin  and  mucous  membranes  and  of  the  conjunctiva 
offer  other  avenues  of  entrance.  The  precise  manner  of  communication  in  these 
cases  is  obscure,  but  careful  search  will  reveal  in  the  majority  of  cases  the  place 
of  infection,  because  the  bacteria  which  are  the  real  cause  of  the  disease  must 
have  penetrated  into  the  body  from  the  external  world.  When  it  is  once  in  the 
system,  it  can  be  disseminated  through  various  channels.  It  may  be  carried 
by  the  lymphatics  into  the  general  circulation  or  a  purulent  phlebitis  may  be 
excited  at  the  point  of  infection,  and  this  in  turn  may  excite  by  embolism 
analogous  lesions  in  other  parts  of  the  body.  The  most  striking  feature  at 
autopsy  is  that  there  is  never  a  lesion  of  one  organ  exclusively.  Several  or, 
it  may  be,  almost  all  the  organs  and  systems  exhibit  foci  of  disease. 

Symptoms. — These  usually  begin  in  the  first  week,  never  later  than  the 
twelfth  day — and  are  those  of  a  general  septic  poisoning  with  the  local  manifes- 
tations at  the  point  of  entrance.  The  fever  is  characteristically  irregular.  It 
may  look  like  typhoid  fever  or  so  closely  resemble  quotidian  or  even  tertian 
intermittent  fever  as  to  lead  to  a  wrong  diagnosis.  Other  cases  show  little  or 
no  elevation  of  temperature.  Cutaneous  symptoms,  icterus,  and  either  puncti- 
form  petechias  or  extensive  hemorrhages  are  common.  The  pulse  is  generally 
rapid  and  of  poor  quality  and  the  respiration  is  disturbed.  Emaciation  always 
occurs.  The  nervous  symptoms  are  restlessness,  irritability,  and  muscular 
twitchings,  with  stupor  or  convulsions  in  the  later  stages.  The  abdomen  is 
generally  swollen  and  tender,  and  we  are  able  at  times,  by  pressing  along  the 
abdominal  walls  toward  the  umbilicus,  to  squeeze  out  a  few  drops  of  purulent 
material.  The  spleen  may  be  enlarged  and  palpable.  There  are  sometimes 
severe  intestinal  symptoms,  a  septic  diarrhea  with  greenish  or  dark  or  bloody 
stools  of  a  very  foul  odor.  The  inflammatory  processes  in  the  brain,  lungs, 
and  heart  often  fail  to  give  well-defined  symptoms. 


842  THE  PATHOLOGY  OF   THE  NEWLY  BORN. 

Diagnosis. — The  diagnosis  of  septic  infection  is  not  difficult  in  well-marked 
cases,  particularly  if  the  mother  develops  puerperal  septicemia.  It  is  more 
difficult  in  isolated  cases  in  which  no  entrance  for  bacteria  can  be  discovered, 
when  the  symptoms  are  ill  defined,  and  when  the  child  comes  under  observation 
late  with  an  imperfect  history.  Inflammation  of  the  nose,  6)^6,  or  joints  should 
suggest  the  possibilities  of  the  case,  the  importance  of  not  regarding  any  single 
local  process  as  the  whole  cause  of  the  illness  being  borne  in  mind. 

Prognosis. — This  should  be  guarded  even  in  the  milder  forms.  The  severe 
cases  are  generally  fatal,  owing  to  the  feeble  resistant  power  of  the  infant. 

Treatment. — In  the  entire  subject  of  septic  infection  nothing  is  so  important 
as  the  means  employed  for  its  prevention.  Antisepsis  in  its  relation  to  delivery 
and  the  care  of  the  infant  is  capable  of  preventing  the  disease.  It  is  the  duty 
of  the  physician  to  carry  out  the  strictest  antiseptic  details  in  every  case  of  labor. 
The  utmost  aseptic  care  must  be  observed  in  ligating  the  cord  and  in  dressing 
it.  When  infection  occurs,  the  infant  should  be  isolated  at  once.  Since  there 
is  no  specific  for  septic  infection  the  remedial  treatment  can  only  be  sympto- 
matic. The  inflammatory  processes  within  the  body  cannot  be  attacked 
directly,  and  medicinal  methods  are  resolved  into  proper  feeding  and  necessary 
stimulation.     External  suppurative  processes  require  surgical  procedure. 

I.  Umbilical  Sepsis. — This  variety  represents  the  type  of  sepsis  neonatorum, 
and  perhaps  four-fifths  of  the  clinical  material.  The  cord  may  be  infected 
either  at  the  time  of  ligation  or  afterward  during  the  sloughing  and  healing 
periods.  Contaminated  ligature  material  and  dressings  are  chiefly  responsible 
for  infection,  but  after  the  stump  of  the  cord  has  fallen  the  often  immature 
scar  is  still  exposed  to  the  action  of  pathogenic  germs.  Before  sloughing,  the 
arteries,  veins,  and  lymphatics  are  all  capable  of  absorption,  but  afterward 
the  vein  alone,  which  often  retains  some  of  its  lumen  for  a  considerable  period, 
is  held  to  be  responsible  for  infection.  The  subject  of  umbilical  sepsis  is  one 
of  extreme  perplexity.  The  local  lesions  exhibit  the  greatest  divergence  of 
type.  While  in  one  series  of  cases  arteritis  predominates,  a  second  reporter 
finds  hardly  any  lesion  but  phlebitis,  and  a  third  finds  more  lymphangitis  than 
either  of  the  other  lesions.  The  same  absence  of  law  is  seen  in  the  consecutive 
lesions.  In  some  cases  the  local  lesions,  of  whatever  nature  and  severity, 
remain  localized  throughout.  In  other  cases  generalization  occurs,  sometimes 
rapid  and  fatal,  at  other  times  more  deliberate  and  less  malignant.  The  follow- 
ing classification  of  umbilical  sepsis  is  now  recognized  at  the  Tamier  Clinique 
(Paris):  (i)  Infection  of  the  cord  proper.  This  occurs  only  in  putrefaction  of 
the  stump.  (2)  Infection  of  the  granulation  tissue  of  the  wound  after  detach- 
ment of  the  stump.  This  occurs  when  for  some  reason  the  cicatrization  is  not 
complete.  A  minute  wound  is  left  which  suppurates  and  sometimes  produces 
excessive  granulations.  The  discharge  may  be  considerable,  and  is  then  known 
as  blennorrhea  of  the  umbilicus;  when  the  granulations  attain  a  large  size,  they 
are  known  as  umbilical  fungus.  (3)  Infection  of  the  periumbilical  tissues  (skin, 
subcutaneous  tissue,  lymphatics,  etc.).  This  is  manifested  by  erysipelas  or 
lymphangitis,  with  or  without  abscess  formation.  In  rare  cases  gangrene 
occurs,  with  the  formation  of  the  so-called  umbilical  ulcer  of  former  days. 
Another  type  of  local  infection  is  periumbilical  pemphigus.  (See  Sepsis  of  the 
Skin.)  Phlegmon  of  the  periumbilical  region  is  indicated  by  the  formation 
of  an  indurated  mass  about  the  cord.  Suppuration  does  not  occur  invariably, 
although  abscess-formation  and  sloughing  form  the  usual  termination.  All  the 
preceding  forms  of  sepsis  are  purely  local;  and  in  order  that  general  infection 
should  occur,  it  is  necessary  for  the  vessels  of  the  cord  to  be  involved.     Hence 


DISEASES  -DUE   TO   BACTERIA   AND   FUNGI.  843 

the  final  type:  (4)  Infection  of  the  umbilical  vessels.  This  is  able  to  occur  with 
or  without  local  mischief.  The  microorganisms  may  enter  the  circulation  imme- 
diately and  set  up  fatal  sepsis.  It  is  possible  that  a  very  slight,  transitory  local 
reaction  always  occurs,  but  it  is  frequently  impossible  to  demonstrate  its  existence. 
Treatment. — Local  sepsis  is  managed  on  ordinary  surgical  antiseptic  princi- 
ples. Exuberant  granulations  should  be  touched  with  tincture  of  iodine  or 
nitrate  of  silver.  Accumulations  of  pus  should  be  evacuated  and  pyogenic 
surfaces  irrigated.  For  an  ordinary  dressing  an  antiseptic  powder  (boric  acid) 
may  be  used.     In  the  more  severe  types  ichthyol,  50  per  cent.,  is  recommended. 

2.  Septic  Coryza. — The  coryza  of  the  newly  bom  is  not  necessarily  due  to 
exposure.  According  to  Bar,  it  is  frequently  encountered  in  children  who  have 
been  exposed  to  the  contact  of  septic  amniotic  fluid.  Despite  its  infectious 
character,  it  is  essentially  a  benign  and  self-limited  affection,  and  only  excep- 
tionally does  the  inflammatory  process  invade  the  sinuses  and  middle  ear.  It 
has  recently  been  claimed  that  many  children  are  bom  with  adenoids,  and 
that  this  condition  is  manifested  by  a  coryza  neonatorum.  The  treatment  is 
carried  out  along  the  same  lines  as  that  in  older  individuals.  At  the  Tamier 
Clinique  mentholized  oil  is  applied  by  a  post-nasal  tube  of  special  pattern. 

3.  Septic  Pneumonia. — The  subject  of  pneumonia  during  the  first  few  da3^s 
of  life  is  one  of  great  obscurity,  and  doubtless  comprises  several  quite  distinct 
conditions:  (i)  In  aspiration-pneumonia,  which  is  a  simple  catarrhal  process,  it 
is  conceivable  that  the  amniotic  fluid  aspirated  intra  partum  might  be  septic 
and  thereby  directly  infect  the  bronchi  with  streptococci,  etc.  When  Bar  states 
that  infectious  pneumonia  is  often  seen  after  a  child  has  breathed  in  utero, 
he  alludes  to  a  condition  which  is  by  no  means  necessarily  septic.  (See  Aspira- 
tion-pneumonia.) The  course  of  this  affection  as  described  by  Bar  is  that  of 
this  simple  irritant  type.  (2)  Since  bronchopneumonia  is  a  deadly  foe  of 
infancy  in  general,  it  is  more  than  likely  that  many  cases  in  the  newly  bom 
are  derived  in  the  ordinary  way,  from  epidemic  influence,  and  do  not  represent 
a  type  of  neonatal  disease.  (3)  Holt  and  other  pediatrists  describe  a  well- 
marked  form  of  septic  purulent  pleuropneumonia  which  is  not  recognizable 
during  life.  Since  it  often  accompanies  sepsis  in  other  localities,  it  doubtless 
represents  a  phenomenon  of  general  infection,  and  corresponds  to  the  purulent 
pleurisy  of  the  newly  born  described  by  Bar . 

4.  Gastro-intestinal  Sepsis. — Some  of  these  infections  may  date  from  the 
ante  partum  or  intra  partum  period,  as  when  the  fetus  swallows  septic  amniotic 
fluid.  The  cause  most  in  evidence  after  delivery  would  be  nursing  an  infected 
nipple  or  contact  of  the  mouth  with  some  unclean  object.  Some  of  the  expres- 
sions of  this  sepsis  of  buccal  origin  are  as  follows: 

(i)  Ulcerous  Stomatitis. — This  condition  is  usually  due  to  the  strepto- 
coccus, and  has  received  numerous  designations.  It  appears  in  the  form  of 
multiple  plaques  of  a  grayish  hue  representing  a  diphtheroid  false  membrane, 
which  when  removed  discloses  ulcerated  surfaces  with  sharply  cut  borders. 
Their  number  and  site  are  often  characteristic,  there  being  two  plaques  seated 
symmetrically  on  the  pterygoid  border  of  the  vault  of  the  palate.  In  some 
cases  they  are  seated  about  the  frenula  of  the  lips.  The  course  pursued  is  usually 
benign,  but  erysipelas  has  sometimes  been  traced  to  the  lesions. 

(2)  Gangrenous  Stomatitis  (Cancrum  Oris,  Noma). — This  disease  is 
rare.  It  occurs  also  in  other  situations  besides  the  mouth,  such  as  the  female  geni- 
tals, the  nose,  and  the  ear.  It  generally  complicates  some  exhausting  disease, 
such  as  measles,  the  child  being  always  in  a  weakened  condition.  Every  case 
must  be  isolated  in  order  to  avoid  the  spread  of  the  disease. 


844  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 

(3)  Parotitis. — Both  the  parotid  and  the  submaxillary  glands  have  been  in- 
fected apparently  by  the  migration  of  pyogenic  germs  from  the  mouth  along 
the  excretory  ducts.  At  first  pus  discharges  by  the  latter  structures,  but  in 
time  these  become  clogged  and  incisions  are  necessitated. 

(4)  Retropharyngeal  Abscess. — This  aflection,  which,  according  to  Bar, 
is  often  overlooked,  occurs  as  a  variety  of  buccal  sepsis.  On  account  of  the 
resulting  dysphagia  the  infant  will  perish  unless  relieved.  There  is  also  a 
marked  constitutional  reaction  in  these  cases. 

(5)  Gastro-enteritis.  —  Of  recent  years  severe  streptococcus  gastro- 
enteritis, followed  perhaps  by  general  sepsis,  has  been  traced  to  nursing  by 
the  newly  born  from  an  infected  breast.  If  the  condition  cannot  be  explained 
in  this  manner  it  may  have  been  due  possibly  to  intra-partum  infection.  The 
disease  begins  with  vomiting  and  diarrhea,  the  ejected  matter  having  a  foul 
odor.  If  the  infection  is  of  a  mild  local  type,  the  symptoms  disappear  within 
a  few  days.  Otherwise  we  see  persistent  diarrhea  develop,  with  inanition  and 
evidences  of  systemic  infection.  If  the  infant  continues  to  absorb  pus  from  the 
infected  breast,  the  chances  of  a  severe  type  of  infection  are  increased. 

5.  Cutaneous  Sepsis. — (i)  Dermatitis  Exfoliativa  Neonatorum  (Ritter's 
Disease). — Definition:  An  exfoliative  process  in  the  skin  of  the  newly  bom 
which  is  believed  to  bear  the  same  relation  to  pemphigus  neonatorum  that 
exfoliative  pemphigus  bears  to  common  pemphigus  in  adult  life.  Etiology:  Rit- 
ter's disease  is  believed  to  be  due  entirely  to  septic  infection  of  the  child  from 
the  maternal  passages,  from  midwives,  etc.  The  ordinary  exciters  of  suppura- 
tion may  be  cultivated  from  the  skin.  Quasi-epidemics  have  occurred.  Symp- 
toms: The  affection  usually  begins  about  the  mouth  and  extends  over  the  entire 
surface.  The  skin  becomes  intensely  red  and  desquamates  in  large,  loose  flakes, 
which  tend  to  adhere  to  the  bedding,  etc.  The  temperature  is  subnormal. 
Diagnosis:  There  is  no  affection  of  the  newly  born  which  simulates  Ritter's 
disease.  Progno5W.' About  one-half  the  children  recover.  Relapses  occur.  Treat- 
ment: The  continuous  bath  is  indicated  at  first.  If  impracticable,  alkaline  lotions 
should  be  applied  until  desquamation  ceases,  and  followed  ^yith  ichthyol  ointment. 

(2)  Pemphigus  Acutus  Neonatorum  (Septic  Pemphigus). — Definition:  A 
bullous  exanthem  not  necessarily  the  same  as  pemphigus  in  the  adult.  It 
corresponds  to  some  extent  with  the  bullous  type  of  impetigo  contagiosa. 
Etiology  :  Pemphigus  of  the  newly  bom  appears  to  be  due  to  the  ordinary 
exciters  of  suppuration,  which  may  be  cultivated  from  the  fluid  contents  of 
the  bullae.  The  source  of  the  disease  may  be  the  maternal  passages,  or  other 
infants  who  have  the  same  affection,  etc.  Symptoms:  Within  the  first  few  days 
of  extrauterine  life  bullae  make  their  appearance  upon  some  portion  of  the 
integument  and  tend  to  involve  the  entire  surface.  The  contents  may  be 
serous,  purulent,  or  bloody.  Numerous  evidences  of  general  sepsis  may  become 
apparent.  Diagnosis :  While  a  few  other  diseases  of  the  newly  bom  may  present 
bullae  (syphilis,  erysipelas),  none  should  be  confounded  with  pemphigus.  Prog- 
nosis: This  is  unfavorable  and  worse  in  proportion  to  the  amount  of  suppuration, 
hemorrhage,  and  constitutional  disturbance.  Treatment:  The  blebs  should  be 
evacuated,  the  surface  cleansed,  and  ichthyol  ointment  (50  per  cent.)  applied. 
Measures  must  be  directed  against  the  constitutional  infection. 

(3)  Impetigo  Contagiosa  Neonatorum  (Periumbilical  Pemphigus). — 
For  a  description  of  impetigo  contagiosa  as  it  occurs  in  older  children  the  reader 
is  referred  to  works  on  dermatology.  While  the  newly  bom  infant  might 
exhibit  the  ordinary  lesions  of  this  disease  if  exposed  in  an  epidemic,  there  is 
one  individual  phase  which  it  alone  exhibits:  viz.,  the  so-called  periumbilical 


DISEASES  -DUE   TO   BACTERIA   AND  FUNGI.  845 

pemphigus, — in  reality  a  localized  bullous  form  of  impetigo  contagiosa  which 
begins  about  the  navel  during  the  first  few  days  of  life.  Staphylococci  have 
been  cultivated  from  the  contents  of  the  blebs.  This  form  of  impjetigo  is  prob- 
ably due  to  a  mild  local  infection,  and  in  fact  appears  to  differ  only  in  degree 
from  ordinary  pemphigus  neonatorum,  which  sometimes  appears  to  start  from 
the  navel.  Periumbilical  pemphigus  should  be  treated  like  the  more  generalized 
form  of  the  disease. 

(4)  Ecthyma  Neqnatorum. — Definition:  Like  the  preceding  affections, 
ecth3^ma  is  a  manifestation  of  sepsis  of  the  newly  born  in  which  cutaneous 
lesions  predominate.  In  the  future  all  these  affections  will  doubtless  be 
regarded  as  types  of  one  fundamental  infection  which  may  announce  itself 
by  various  lesions,  bulls  predominating  in  one  case  and  pustules  in  another. 
It  is  at  present  impossible  to  state  positively  whether  these  eruptions  originate 
in  the  skin  or  are  preceded  by  a  blood  infection.  Ecthymatous  lesions  of  the 
newly  bom  resemble  those  in  the  adult,  and  consist  of  large  subepidermic 
pustules  having  a  broad  indurated  base.  At  this  period  of  life  there  is  a  special 
tendency  for  the  pustule  to  ulcerate.  In  certain  cases  there  is  a  marked  inclina- 
tion toward  ulceration  in  depth  (ecthyma  terebrante).  Etiology:  The  ordinary 
exciters  of  suppuration  are  usually  at  fault  (staphylococci  and  streptococci);  in 
particular  instances  some  other  germ,  such  as  Bacillus  pyocyaneus,  may  be 
responsible  for  the  lesions.  According  to  the  obstetricians  of  the  Paris  clinics, 
this  ecthyma  occurs  by  preference  in  premature  and  congenitally  feeble  children, 
in  the  cachectic,  etc.  Symptoms:  The  lesions  occur  most  frequently  on  the 
head,  neck,  and  abdomen.  When  the  process  is  at  its  height,  they  appear 
chiefly  as  ulcers  with  rounded  borders  surrounded  by  areas  of  a  purple  hue.  The 
development  of  the  pustules  is  preceded  or  accompanied  by  fever,  vomiting, 
diarrhea,  etc.  A  special  localized  form  of  this  suppuration  is  sometimes  seen 
about  the  nails  of  the  newly  born — the  so-called  "run  round."  Diagnosis:  The 
recognition  of  the  pustulo-ulcerous  lesions  of  ecthyma  is  not  difficult,  and  the 
real  diagnostic  difficulty  lies  in  arriving  at  a  knowledge  of  the  predisposing 
cause;  for  clinically  ecthyma,  while  technically  a  contagious  disease,  is  rather 
the  expression  of  an  underlying  cachectic  state.  Treatment:  Measures  must  be 
directed  to  the  general  condition.  If  the  patient  presents  crusted  lesions,  the 
scabs  must  be  removed  by  sweet  oil,  etc.  The  exposed  surface  and  ulcers  in 
general  should  be  treated  with  mild  solutions  of  nitrate  of  silver. 

(5)  Multiple  Abscesses. — Multiple  abscesses  in  the  newly  bom  consist  of 
collections  of  pus  of  varying  size  and  depth  beneath  the  skin.  Two  types  occur: 
viz.,  the  superficial  or  benign  and  the  deep  or  septic.  Etiology:  The  superficial 
or  benign  type  of  abscess  appears  to  represent  a  local  infection  with  the  sta- 
phylococcus or  streptococcus,  which  germs  are  often  derived  originally  from 
some  maternal  lesion  such  as  purulent  mastitis.  The  deeper  sort  may  form  in  the 
subcutaneous  tissue  or  between  contiguous  muscles.  In  these  cases  the  infec- 
tious pus  appears  to  have  been  swallowed  by  the  infant  while  nursing  from  an 
infected  breast.  Abscesses  coexist  in  the  large  viscera,  and  the  condition  is 
really  one  of  profound  pyemia.  Symptoms:  These  abscesses  cause  swellings  which 
may  be  as  small  as  a  pea  or  as  large  as  a  small  hen's  egg.  In  the  benign  form  the 
abscesses  appear  in  crops,  and  are  usually  of  small  dimensions.  The  larger,  more 
deeply  placed  abscesses  of  septic  origin  behave  very  much  like  ordinary  cold 
abscesses.  Their  number  and  extent  make  the  condition  most  serious,  to  say 
nothing  of  the  great  likelihood  of  the  involvement  of  subjacent  viscera. 
Bar  speaks  of  opening  forty-five  of  these  abscesses  in  one  child.  Death  finally 
occurred,  and  on  autopsy  a  collection  of  pus  was  found  in  the  posterior  mediasti- 


846  THE  PATHOLOGY  OF   THE  NEWLY  BORN. 

num.  Diagnosis:  This  should  readily  be  made  with  the  exploring  needle  if 
any  doubt  arises  as  to  the  nature  of  the  affection.  Treatment:  A  newly  born 
infant  should  never  nurse  from  a  breast  the  seat  of  abscess,  or  with  any  lesion 
whatever  of  the  nipple,  areola,  or  breast.  If  abscesses  have  formed,  they 
should  be  evacuated,  and  the  larger  sort  may  require  drainage.  If  the  earliest 
abscesses  are  evacuated,  irrigated  with  sublimate,  and  sealed  with  collodion, 
the  spread  of  the  disease  may  be  partially  checked. 

(6)  Erysipelas. — Erysipelas  in  the  newly  bom,  as  in  adults,  is  an  inflam- 
mation of  the  skin  due  to  a  specific  germ,  Streptococcus  erysipelatis.  It  is 
especially  seen  in  the  first  two  weeks  of  life,  and  usually  has  its  origin  in  the 
navel,  the  small  fissures  of  the  anus,  or  abrasions  of  the  skin.  Pathology:  The 
skin  and  subjacent  connective  tissue  are  congested  and  swollen  and  infiltrated 
with  serum,  fibrin,  and  leucocytes,  the  process  continuing  in  many  cases  to 
suppuration,  ulceration,  and  gangrene.  Metastases  may  form  in  the  lungs, 
heart,  brain,  kidney,  and  spleen.  If  the  umbilicus  is  the  primary  seat,  it  is 
likely  that  localized  or  general  peritonitis  will  follow.  Acute  degeneration  of 
the  liver  and  kidneys  is  a  common  step  in  the  progress  of  the  infection.  Symp- 
toms: Invasion  is  usually  marked  by  vomiting,  high  fever,  and  severe  pros- 
tration. Locally  the  skin  is  hot,  dry,  hyperemic,  and  tender,  and  the  inflamed 
area  rapidly  increases  in  size.  Restlessness  and  vomiting  with  the  fever  and 
prostration  persist  during  the  course  of  the  disease,  which  in  the  newly  bom 
usually  ends  disastrously.  Especially  is  the  prognosis  bad  when  the  umbilicus 
is  the  starting-point.  Treatment:  Isolation  should  be  practised  at  once.  Locally 
an  ointment  of  ichthyol,  lo  to  20  per  cent,  in  lanolin,  should  be  applied  continu- 
ously over  the  inflamed  parts.  If  suppuration  occurs,  wet  dressings  of  lysol, 
creolin,  or  bichloride  may  be  of  advantage.  Constitutionally  we  must  support 
the  child  with  alcohol  and  strychnin  in  free  doses  and  the  regulated  use  of  baths 
and  packs.  Artificial  feeding  may  be  required  during  the  entire  illness,  par- 
ticularly when  there  is  any  danger  of  infecting  the  mother's  breasts. 

6.  Tetanus. — Tetanus  is  an  acute  infectious  disease  of  rather  infrequent 
occurrence,  the  main  symptom  of  which  is  tonic  spasm  involving  the  muscles  of 
the  jaws  and  neck  or  the  entire  muscular  system.  There  is  no  ground  for 
establishing  tetanus  neonatorum  as  a  distinct  form,  since  its  etiology  and  course 
are  analogous  at  all  times  and  at  all  ages.  The  specific  cause  is  a  bacillus  which 
is  rather  widespread  and  in  some  places  very  abundant,  occurring  in  the  soil 
with  other  germs.  It  produces  no  special  local  lesion,  but  affects  the  body  by 
its  elaboration  of  tetano-toxin,  a  most  virulent  poison.  The  germ  enters  the 
body  through  abrasions  and  fresh-cut  surfaces,  more  often  through  the  umbilicus. 
Pathology:  No  characteristic  lesions  have  been  found  in  the  spinal  cord  or  brain. 
Symptoms:  These  may  develop  within  a  few  days  after  inoculation  or  they  may 
be  deferred  for  one  or  two  weeks.  Ordinarily  the  first  thing  noticed  is  the  in- 
fant's inability  to  nurse,  due  to  .rigidity  of  the  muscles  of  the  face  and  jaws  and 
nape  of  the  neck.  This  rigidity  spreads  by  degrees  to  the  muscles  of  the  trunk 
and  extremities.  In  many  cases  the  continuous  tonic  spasm  is  occasionally 
interrupted  by  sudden  and  irregular  paroxysms,  during  which  all  the  affected 
muscles  become  still  more  tense  and  opisthotonos  is  pronounced.  The  jaws 
are  firmly  pressed  together  and  can  be  opened  but  slightly.  The  face  has  a 
peculiar  drawn  painful  expression,  the  respirations  are  embarrassed,  the  pulse 
is  rapid  and  weak,  and  prostration  is  pronounced.  Fever  is  generally  present, 
often  rising  to  105°  F.  before  death.  Recovery  sometimes  occurs  in  the  milder 
forms,  but  when  the  disease  is  once  established  the  prognosis  is  bad.  Treat- 
ment: Avoid  infection  by  observing  perfect  aseptic  precautions  in  the  dressing 


DISEASES  OF   UNKNOWN  NATURE.  847 

of  the  cord  and  the  treatment  of  denuded  surfaces.  When  systemic  poisoning 
is  evident,  the  point  of  entrance  should  be  attacked  and  made  as  clean  as  possible. 
Antitoxin  should  be  administered  by  the  hypodermic  method.  Further  than 
this  we  must  rely  upon  the  symptomatic  remedies  with  the  aim  of  preserving  life. 
Remedies  which  lessen  the  irritability  of  the  nervous  centers,  such  as  potassium 
bromide,  gr.  4  to  8,  every  two  hours;  or  chloral  hydrate,  gr.  2  to  4,  every  one  or 
two  hours  per  rectum,  have  a  certain  amount  of  value.  Calabar  bean  has  been 
much  used  in  doses  of  gr.  yV  to  ^  several  times  daily  by  the  hypodermic  method. 
All  unnecessary  handling  should  be  avoided  and  everything  done  to  prevent  dis- 
turbing the  infant.  Feeding  by  the  nasal  tube  is  necessary  when  the  jaws  can- 
not be  forced  apart,  and  stimulants  may  be  given  by  the  same  channel.  Spinal 
puncture  has  given  good  results. 


DISEASES  DUE  TO  FUNGI. 

Although  there  is  no  positive  proof  that  these  conditions  are  due  to  fungi, 
still  they  are  most  conveniently  classed  here. 

7.  Aphthae. — Aphthae,  sometimes  called  vesicular  or  follicular  stomatitis,  is  a 
morbid  condition  of  the  mouth  characterized  in  the  early  stages  by  the  appear- 
ance of  whitish  vesicles  followed  by  superficial  ulcers,  mostly  on  the  inside 
nf  the  lips  and  the  edges  of  the  tongue.  It  appears  at  any  time  in  infancy,  but 
infrequently  in  the  newly  born.  Authorities  tend  to  the  belief  that  it  is  nervous 
in  origin.  So  far  there  is  no  testimony  to  prove  its  bacterial  origin.  Probably 
in  some  instances  the  exciting  cause  is  some  derangement  of  the  digestive 
organs  which  is  not  appreciable.  Treatment:  Prophylaxis  consists  in  scrup- 
ulous cleanliness  of  the  mouth,  especially  at  the  time  of  nursing.  Cold  water 
should  be  given  freely.  The  mouth  should  be  kept  properly  cleansed  with 
solutions  of  boric  acid  or  Dobell's  solution.  Powdered  alum  dusted  on  or  the 
judicious  use  of  solid  alum  or  the  solid  stick  of  silver  nitrate  generally  hastens 
the  process  of  healing. 

8.  Thrush. — The  term  thrush  signifies  a  form  of  inflammation  of  the  buccal 
mucous  membrane,  the  peculiar  feature  of  which  is  the  formation  of  curd-like 
points  or  patches  on  the  parts  involved.  It  occurs  any  time  in  the  first  few 
months  of  life.  It  has  been  definitely  settled  that  Oidium  albicans  is  not 
the  cause,  but  another  variety  of  fungus,  parasitic  in  character,  the  nature  of 
which  has  not  yet  been  fully  determined.  It  is  more  often  seen  in  infants 
who  suffer  from  inattention  and  uncleanliness  and  in  those  who  are  constitu- 
tionally enfeebled.  Treatment:  Prophylaxis  is  most  important;  careful  attention 
to  cleanliness  will  prevent  the  majority  of  cases. 


VI.  DISEASES  OF  UNKNOWN  NATURE. 

I.  Omphalorrhagia.  2.  Melena.  j.  Miscellaneous  Hemorrhages.  4.  From  Genitals  in 
Female  Infants.  5.  Sclerema  Neonatorum.  6.  Buhl's  Disease.  7.  WinckeVs  Disease. 
8.  Mastitis,     g.  Jaundice. 

The  preceding  causes  named  under  Sections  I  to  V,  and  often  the  cooperation 
of  two  or  more  of  them  in  a  single  case,  are  responsible  for  the  large  mortality 
among  the  newly  bom.  The  vital  statistics  of  New  York  show  that  in  about  6 
per  cent,  of  all  births  the  children  die  within  the  first  four  weeks.  If  to  this 
number  we  add  the  still-births,  we  find  that  in  14  per  cent,  of  all  births  the 


848  THE  PATHOLOGY   OF   THE  NEWLY  BORN. 

children  are  unable  to  survive.  Eross  made  an  extensive  collective  investiga- 
tion in  1893  and  found  that  10  per  cent,  of  all  children  die  within  the  first  month. 
This  author  assigned  "congenital  debility"  as  the  cause  of  death  in  these  cases 
in  over  50  per  cent,  of  the  material.  If  more  of  these  cases  came  to  autopsy 
the  matter  would  assume  a  different  complexion.  Thus,  Brothers  *  made  47 
post-mortems  on  children  who  were  either  still-born  or  who  died  within  a  fort 
night  after  birth,  and  found  in  most  cases  definite  organic  lesion  sufficient  to 
have  caused  death.  Disease  acquired  after  birth  is  extremely  rare.  (Brothers 
records  one  case  of  intussusception.)  Intra-partum  affections,  on  the  other 
hand,  must  be  very  common,  judging  from  the  amount  of  cerebral  hemorrhage 
and  catarrhal  pneumonia  (provided  that  the  latter  is  due  to  aspiration  of  amniotic 
fluid).  Enough  has  been  said  to  illustrate  the  great  complexity  of  the  subject 
of  infantile  mortality.  There  can  be  little  doubt  that  a  condition  of  subdevelop- 
ment,  whether  due  to  prematurity  or  severe  maternal  disease  or  both,  furnishes 
a  very  strong  predisposition  to  all  the  other  conditions  which  menace  the  newly 
born.  If  we  exclude  from  consideration  that  element  of  birth  mortality  which 
is  due  to  actual  fetal  disease  and  malformation  and  to  infection  intra  partum 
and  post  partum,  we  may  recognize  as  the  two  leading  factors  the  subdevel- 
opment  of  the  fetus  on  the  one  hand,  and  dystocia  on  the  other.  The 
condition  of  subdevelopment,  which  is  practically  synonymous  with  congenital 
debility,  is  probably  responsible  for  more  than  one-half  of  all  infantile  mortality, 
and  the  actual  exciting  cause  of  death  is  of  no  special  significance.  The  mor- 
tality from  dystocia  is  due  principally  to  asphyxia  and  cerebral  hemorrhage, 
with  a  certain  proportion  of  deaths  from  aspiration-pneumonia  as  a  result  of  the 
entrance  of  amniotic  fluid  into  the  lungs. 

Hemorrhages  in  General. — Somewhat  different  in  character  from  the  preced- 
ing is  the  marked  tendency  of  the  neonatal  blood-vessels  to  rupture,  insomuch 
that  a  sort  of  hemorrhagic  diathesis  appears  to  exist.  Hemorrhages  either  occur 
independently  or  complicate  other  conditions,  especially  infectious  conditions. 
Independent  hemorrhages  occur  principally  from  the  navel  (omphalorrhagia), 
intestinal  canal  (melena),  and  the  subcutaneous  tissues.,  Hemorrhages  into  the 
suprarenal  bodies  have  been  noted.  They  are  of  rare  occurrence  and  have 
no  connection  with  hemophilia,  since  the  disposition  to  bleed  ceases  with  the 
neonatal  period.  The  true  hemorrhagic  diathesis  is  very  seldom  manifested 
at  birth.  Traumatic  hemorrhages  are  not  considered  in  this  connection, 
although  the  tendency  of  the  newly  born  to  bleed  acts  undoubtedly  as  a 
predisposing  cause.  Neither  are  the  hemorrhages  which  characterize  syphilis 
in  the  newly  born  and  septic  infection  post  partum  included  here.  The  dis- 
position of  the  newly  born  to  hemorrhage  may  be  attributed  to  the  new  demands 
made  upon  the  circulation  by  extrauterine  life  and  the  extreme  fragility  of  the 
capillaries.  The  blood  itself  may  undergo  some  peculiar  change,  and  the  fact  that 
actual  extensive  hemorrhage  is  not  of  common  occurrence  has  caused  the  belief 
in  some  quarters  that  the  blood  is  altered  by  some  agency,  perhaps  a  bacterium, 
before  it  can  escape  in  such  large  quantities.  These  hemorrhages  are  oftener 
fatal  than  not,  but  if  the  child  can  survive  beyond  the  neonatal  period  it  is 
usually  safe,  for  then  the  unknown  process  of  readjustment  appears  to  be  com- 
pleted. 

I.  Omphalorrhagia. — This  condition  is  associated  with  the  falling  of  the 
cord  about  the  fifth  or  seventh  day  post  partum.  It  is  insidious  in  character, 
consisting  of  a  general  sanguineous  oozing  from  the  umbilical  stump.  The  blood 
shows  little  tendency  to  coagulate.     When  the  hemorrhage  is  not  fatal,   its 

*  "Infantile  Mortality,"  1896 


'   DISEASES  OF   UNKNOWN  NATURE.  849 

tendency  is  to  spontaneous  arrest  within  a  few  hours  or  at  most  days.  Other 
hemorrhages  may  coexist,  as  may  also  other  neonatal  diseases,  and  in  some 
cases  omphalorrhagia  is  simply  a  collateral  phenomenon  of  syphilis  neonatorum 
or  umbilical  sepsis.  The  prognosis  is  almost  hopeless,  as  the  escape  of  blood  is 
with  difficulty  checked,  and,  moreover,  death  often  occurs  even  after  the  bleed- 
ing vessels  have  been  completely  ligated;  suggesting  that  the  fatal  termination 
is  due  not  to  the  escape  of  blood,  but  to  the  basic  condition  which  makes 
the  latter  possible.  The  best  treatment  is  probably  compression  with  hare-lip 
pins,  which  will  do  all  that  can  be  done  by  hemostatic  procedures.  In  tliis 
connection  it  may  be  mentioned  that  fatal  omphalorrhagia  may  result  from 
failure  properly  to  ligate  the  cord  at  birth.  Fortunately,  omphalorrhagia  occurs 
very  rarely. 

2.  Helena,  or  Gastro-intestinal  Hemorrhage. — Hemorrhage — generally  capil- 
lary— from  the  gastro-intestinal  mucous  surface  occurs  sufficiently  often  in  the 
early  days  of  life  to  make  it  a  disease  of  some  importance.  It  rarely  occurs  after 
the  twelfth  day.  Etiology:  No  satisfactory  cause  has  yet  been  assigned,  but  the 
hemorrhage  is  due,  no  doubt,  to  changes  in  the  blood  or  in  the  blood-vessels  or  in 
both.  There  is  reason  to  believe  also  that  a  tardy  or  incomplete  establishment 
of  the  respiratory  and  circulatory  functions,  giving  rise  to  venous  stasis,  is  an  im- 
portant factor  in  an  etiologica  way.  Hereditary  syphilis  is  associated  with  a  small 
percentage  of  cases.  A  microbic  theory  has  been  advanced  but  not  accom- 
panied with  testimony  sufficient  to  be  of  value.  It  develops  at  any  time  during 
the  first  week  of  life.  In  three  cases  described  by  Brothers,  omphalorrhagia 
coexisted  in  all.  Pathology:  Many  cases  show  no  lesion  at  autopsy  except  the 
hemorrhage  and  the  blanching  of  the  involved  mucous  membranes.  There  may 
also  be  ecchymoses  of  the  mucous  membrane.  Ulcers  are  found  in  the  stomach 
and  intestine  in  a  small  proportion  of  cases.  These  ulcers  are  multiple  and  small, 
usually  superficial,  but  may  extend  to  the  muscular  coat  or  even  perforate  the 
intestine.  The  cause  of  these  ulcers  is  somewhat  obscure,  but  some  are  prob- 
ably of  infectious  origin,  while  others  are  due  to  thrombi  in  the  blood-vessels  of 
the  mucous  membrane.  In  a  case  in  my  service  at  the  Emergency  Hospital, 
blood  was  vomited  and  passed  by  rectum.  The  autopsy  disclosed  no  ulcers 
of  the  stomach  or  intestines.  Death  occurred  on  the  tenth  day  post  partum. 
Symptoms:  The  presence  of  blood  is  generally  the  first  symptom  to  attract 
attention,  and  blood  in  the  stools  is  much  more  common  than  hemorrhage 
from  the  stomach.  The  general  condition  of  the  infant  may  be  good  or  there 
may  be  pale  skin,  feeble  heart  action,  and  decided  weakness.  Vomited  blood 
is  usually  dark  in  color  and  small  in  quantity,  the  stools  are  always  dark,  the 
blood  and  fecal  matter  being  closely  associated.  Clots  in  the  stools  are  not 
common.  Occasionally  death  follows  internal  hemorrhage  and  the  condition  is 
discovered  only  at  autopsy.  It  should  be  remembered  that  vomiting  of  blood 
may  result  from  nursing  from  a  fissured  nipple.  The  prognosis  depends  upon 
the  general  condition  of  the  infant  and  the  frequency  and  amount  of  the  hemor- 
rhages. The  mortality  has  been  estimated  as  high  as  50  per  cent.  Treatment: 
General  measures,  such  as  proper  food  and  appropriate  stimulation  directed 
to  the  maintenance  of  the  bodily  strength,  should  be  resorted  to.  Astringents, 
either  by  mouth  or  per  rectum  or  subcutaneously,  have  no  influence  upon  the 
bleeding.     Suprarenal  extract  given  by  mouth  is  held  to  be  of  benefit. 

3.  Miscellaneous  Hemorrhages. — Other  localizations  of  this  general  hemor- 
rhagic tendency  are  (3)  the  subcutaneous  tissue  (purpura  hgemorrhagica),  the 
extravasations  occurring  by  preference  over  regions  exposed  to  pressure;  uncom- 
plicated purpura  is  a  benign  affection,  although  the  loss  of  blood  may  be  con- 

54 


850  THE  PATHOLOGY   OF   THE  NEWLY   BORN. 

siderable.     (4)  The  urinary  passages  (hematuria)  and  (5)  the  female  genitals, 
where  the  escape  of  blood  suggests  precocious  menstruation  (see  page  850). 

4.  Hemorrhage  from  the  Genitals  in  Female  Infants. — This  hemorrhage  may 
be  a  symptom  of  a  number  of  ver}'-  different  conditions.  In  many  instances  the 
plienomenon  appears  to  be  phj^siological,  and  more  than  once  it  has  foreshadowed 
precocious  menstruation  and  early  sexual  development  (St.  Hilaire  and  others). 
In  these  quasi-menstrual  cases  the  flow  of  blood  begins  a  short  time  after  birth 
and  continues  over  a  space  which  corresponds  to  a  menstrual  epoch.  There  is, 
however,  no  recurrence  on  the  following  month.  In  other  cases  it  appears  to 
have  a  sinister  meaning,  for  it  has  been  noted  as  a  terminal  phenomenon  in 
infants  dying  shortly  after  birth,  especially  premature  infants.  Doleris  *  looks 
upon  such  cases  as  examples  of  a  general  infection  of  doubtful  origin,  and  in  one 
such  instance  found  a  pericardial  effusion  from  which  he  cultivated  staphylococci. 

A  series  of  autopsies  would  doubtless  throw  light  upon  the  nature  of  this 
affection,  or  group  of  affections,  but  few  such  records  exist.  In  one  case  of 
prematurity  Eross  found  blood  in  the  uterine  cavity,  and  an  apparent  condition 
of  hemorrhagic  metritis.  We  may  at  the  present  day  distinguish  between  a 
physiological,  benign  type  of  hemorrhage,  and  another  form  which  appears 
to  stand  in  relation  with  the  uterine  congestion  of  prematurity.  It  is  also 
quite  probable  that  other  conditions  may  produce  this  phenomenon.     I  have 

observed  during  the  past  ten  years 
a  number  of  cases  of  muco-sangui- 
nolent  discharge  from  the  vagina 
in  full-term  healthy  children. 
Mothers  and  nurses  are  often  un- 
duly alarmed  at  its  occurrence.  A 
mild  boric-acid  wash  is  all  the 
treatment  called  for. 

In  addition  to  the  hemorrhagic 

state  and  icterus  which  might  well 
Fig.  xo3i.-Sclekema^of^the  Newly  Born.-         ^^  ^^^^^^    ^^^^^   ^j^-^   ^^^^^^  ^^^^^ 

are  a  number  of  other  affections — 

sclerema.  Buhl's  disease,  Winckel's 

disease,  mastitis,  etc.     It  is  impossible  to  state  whether  the  leading  element  in 

these  cases  is  readjustment,  infection,  or  the  persistence  of  some  intrauterine 

affection. 

5.  Sclerema  Neonatorum. — The  subject  of  sclerema  is  in  a  hopeless  state  of 
confusion.  It  appears  to  attack  the  subdeveloped  child  only,  but  is  much  too 
rare  to  be  ranked  as  a  mere  anomaly  of  readjustment.  It  is  not  necessarily  a  dis- 
ease of  the  newly  born,  and  hence  can  hardly  represent  the  persistence  of  a  fetal 
state.  It  cannot  be  brought  into  relationship  with  an}^  infectious  process.  The 
peculiar  induration  first  appears  in  localities  where  adipose  tissue  is  abundant, 
and  usually  extends  over  most  of  the  subcutaneous  area  (Fig.  103 1).  At  the 
same  time  there  is  a  marked  lowering  of  temperature  with  failure  of  circulation, 
cyanosis  and  cedema  often  appearing.  The  child  seldom  lives  over  three  or 
four  days  from  the  inception  of  the  malady-.  While  the  general  prognosis  is  grave, 
mild  cases  of  sclerema  are  sometimes  saved  by  the  treatment  for  prematurity, 
including  the  incubator.  In  a  certain  number  of  cases  sclerema  has  been  noted 
as  a  mere  terminal  stage  of  exhaustion.    There  is  a  large  amount  of  evidence  that 

*  "  Jour,  de  m6d..  de  Paris,"  1898,  x,  349. 

t  "Dorsal  Sclerema  Neonatorum,"  William  Browning,  "Journal  Cutan.  and  Gen.- 
Urin.  Diseases,"  vol.  xviii,  whole  No.  219,  Dec,  1900. 


DISEASES   OF    UNKNOWN   NATURE. 


851 


the  affection  represents  only  a  high  degree  of  the  defective  readjustment  of  the 
subdeveloped  child.  Unfortunately  all  sorts  of  exceptions  to  general  rules  have 
been  noted.     Ballantyne  even  cites  a  case  in  which  no  adipose  layer  was  present. 

6.  Buhl's  Disease.  7.  Winckel's  Disease. — The  former  has  been  known  as 
"fatty  degeneration  of  the  newly  born,"  and  the  latter  as  "epidemic  hemoglobin- 
uria of  the  newly  born."  Both  conditions  suggest  sepsis  as  the  cause,  Winckel's 
disease  more  so  than  Buhl's,  because  the  former  has  occurred  in  epidemics. 

The  prognosis  is  hopeless  and  the  treatment  entirely  symptomatic  in  both 
these  diseases. 

8.  Mastitis. — Mammary  abscess  belongs  under  "sepsis  neonatorum,"  but  the 
condition  usually  referred  to  as  mastitis  includes  the  condition  of  physiologic^al 
activity  so  often  seen  in  children  of  both  sexes  at  birth,  by  virtue  of  which  milk 
is  for  a  few  days  secreted  in  minute  amounts  (Fig.  1032).  As  a  result  of  handling, 
want  of  cleanliness,  etc.,  pyogenic  germs  may  gain  access  to  these  secreting  glands 
and  local  sepsis  may  result.  (See  Sepsis.)  The  existence  for  two  or  three  weeks 
after  birth  of  mammary  secretion  is 

generally  thought  to  be  physiologi- 
cal. In  any  event,  it  is  quite  com- 
mon. It  is  found  as  frequently  in 
boys  as  in  girls,  the  amount  not 
often  exceeding  a  few  drops.  Its 
chemical  constituents  are  like  those 
of  adult  milk.  The  condition  of 
functional  activity  will  generally 
disappear  spontaneously.  Treat- 
ment: In  the  majority  of  cases  no 
treatment  is  necessary.  When  the 
glands  are  really  inflamed,  an  ap- 
plication of  ichthyol  ointment,  20 
per  cent.,  lead-water  and  laudan- 
um, or  lead  plaster  may  be  made. 
In  the  event  of  pus  formation  im- 
mediate incision  and  evacuation  are  indicated,  together  with  supporting  and 
stimulating  treatment. 

9.  Jaundice. — Icterus  neonatorum  may  also  be  included  among  anomalies  of 
readjustment,  although  in  certain  cases  it  is  a  complication  of  sepsis,  etc.  The 
pathogeny  of  primary  icterus  is  obscure,  although  this  affection  occurs  so  fre- 
quently that  it  may  almost  be  regarded  as  physiological.  It  is  often  associated 
with  uric-acid  infarcts  in  the  kidney.  Primary  icterus  appears  during  the  first 
week  of  life  and  lasts  but  a  few  days.  It  does  not  begin  in  the  conjunctivae, 
which  are  involved  after  the  skin.  The  child  loses  weight  during  the  evolution 
of  the  disease.  It  is  almost  impossible  to  differentiate  primary  icterus  from 
the  jaundice  which  accompanies  sepsis,  syphilis,  malformations  of  the  hepatic 
tissues,  etc.  Nor  is  it  possible  to  distinguish  between  a  primary  icterus  from 
anomalous  action  of  the  liver  and  a  hypothetical  hematogenous  form.  Jaundice 
of  the  newly  bom  might  also  be  of  fetal  origin  in  certain  cases,  and  under  these 
circumstances  the  pigment  would  come  from  the  mother.  Little  or  no  special 
treatment  is  required,  although  syrup  of  rhubarb  and  calomel  are  often  admin- 
istered. 


Fig.  1032. — Bilateral  Mastitis  of  the  Newly' 
Born. — (Author's  case  at  the  Emergency  Hos- 
pital.) 


852  THE  PATHOLOGY  OF   THE  NEWLY   BORN. 


VII.  GENERAL  POST-PARTUM  CONDITIONS. 

;■.  Ulceratton  of  the  Hard  Palate,  Bednar's  Disease.  2.  Sublingual  Cysts,  j.  Vomiting. 
4.  Colic.  5.  Diarrhea.  6.  Constipation.  7.  Intestinal  Obstructions.  8.  Pneumonia. 
Q.  Convulsions.  10.  Infantile  Cachexia.  11.  Sudden  Death.  12.  Medication  of  the 
Newly  Born. 

1.  Ulceration  of  the  Hard  Palate,  Bednar's  Disease. — This  is  characterized 
by  the  formation  upon  the  hard  palate  of  two  ulcers,  one  on  each  side  of  the 
median  line;  occasionally  only  one  may  be  present.  They  are  at  first  super- 
ficial. It  is  supposed  to  be  caused  by  friction  against  the  rubber  nipple,  by 
the  habit  of  tongue-sucking,  or  by  rough  and  careless  manipulations  in  cleansing 
the  child's  mouth.  Marasmus  is  a  predisposing  cause.  The  treatment  is 
removal  of  the  cause  if  possible.  If  marasmus  or  malnutrition  is  present,  a 
cure  may  be  difficult  or  impossible. 

2.  Sublingual  Cysts. — What  is  known  as  the  lingual  duct  is  represented  by 
a  canal  running  from  the  foramen  caecum  between  the  geniohyoglossi  muscles 
to  the  posterior  surface  of  the  hyoid  bone.  In  its  course  cysts  may  develop, 
due  no  doubt  to  an  inclusion  of  a  minute  portion  of  epiblast  or  hypoblast. 
They  are  always  congenital,  but  may  not  become  manifest  for  many  years, 
when  they  may  become  attached  to  the  hyoid  bone  behind  or  to  the  lower 
jaw  in  front.  The  dermoid  variety  are  lined  with  epithelium  and  contain 
sebaceous  matter  and  sometimes  hairs.  Another  variety,  by  far  the  most 
important,  is  ranula,  a  bluish,  semi-transparent,  ovoid  or  round  swelling  with 
thin  walls  located  in  the  floor  of  the  mouth  under  the  fore  part  of  the  tongue. 
They  are  usually  unilateral,  contain  glairy,  mucoid  material,  and  are  painless. 
As  a  rule,  they  are  small,  but  they  may  attain  the  size  of  a  walnut  and  so  inter- 
fere with  speech  and  swallowing.  The  typical  ranula  is  most  frequently  a 
retent  on  cyst  of  the  mucus-secreting  glands  of  the  floor  of  the  mouth.  The 
treatment  is  entirely  surgical.  Radical  extirpation  is  practised  for  dermoids, 
wh^le  incision  and  cauterization  are  the  methods  most  commonly  employed  for 
the  cure  of  ranula. 

3.  Vomiting. — Regurgitation  of  food  is  sometimes  due  to  the  fact  that  the 
child  is  fed  too  often  or  in  too  large  quantity.  Thus  regurgitation  is  of 
frequent  occurrence.  In  other  cases,  and  especially  if  the  vomited  matter 
contains  curds,  some  defect  in  the  preparation  or  composition  of  the  milk  is  to 
be  suspected. 

4.  Colic. — One  of  the  most  common  symptoms  which  the  physician  is  called 
upon  to  treat  is  colic.  Too  often  the  symptom  alone  is  treated  without  proper 
consideration  of  the  etiological  factors  in  the  case.  Etiology:  Some  error  in 
diet  is  almost  always  the  underlying  cause.  In  a  great  majority  of  cases  it 
is  the  proteids  of  the  milk,  although  any  of  its  constituents  may  be  at  fault. 
Flatulence  follows,  due  to  the  formation  in  the  intestine  of  gas  from  fermenta- 
tion or  decomposition,  and  colic  ensues.  All  severe  forms  of  intestinal  inflam- 
mation, chilling  of  the  body-surface,  or  a  diet  containing  cereals  in  excess  are 
prominent  causes.  When  colic  is  unaccompanied  by  flatulence,  the  pain  is  due 
to  muscular  spasm.  It  occurs  in  breast-fed  as  well  as  bottle-fed  children,  and  is 
most  common  during  the  first  three  months.  The  pain  is  often  severe.  Symptoms: 
A  child  with  colic  presents  a  picture  which  is  almost  characteristic.  The  facial  ex- 
pression is  one  of  misery,  crying  is  violent  and  paroxA^smal,  as  a  rule  the  lower 
extremities  are  drawn  up,  the  abdomen  is  tense  and  hard  and  more  or  less 
tympanitic,  and  in  severer  cases  there  is  cold,  clammy  skin,  with  feeble  pulse 
and  possibly  convulsions.     The  expulsion  of  flatus  is  followed  by  almost  imme- 


GENERAL  POST-PARTUM  CONDITIONS. 


8.53 


diate  relief.  The  possibility  of  intussusception  or  appendicitis  must  be  borne  in 
mind.  Treatment:  Recalling  the  fact  that  flatulence  is  the  predominant  cause, 
an  enema  affords  the  greatest  hope  of  speedy  relief.  From  three  to  eight 
ounces  of  lukewarm  water  or  a  smaller  quantity  of  sweet  oil  or  glycerin  is 
ordinarily  effectual.  Heat  to  the  abdomen  and  feet  is  of  value.  Turpentine 
stupes  to  the  abdomen  are  always  grateful.  When  relief  is  afforded,  it  is  wise 
to  purge  with  fractional  doses  of  calomel  or  a  mild  saline.  When  the  muscular 
spasm  is  severe,  opiates  are  indicated.  A  study  of  the  patient's  digestive 
powers  and  scientific  modification  of  its  food  are  demanded  when  attacks  of 
colic  show  a  tendency  to  recur.  During  the  attack  a  drachm  of  soda-mint  or 
a  few  drops  of  gin  or  brandy  in  a  little  warm  water,  or  a  few  drops  of  compound 
tincture  of  cardamom,  may  afford  relief. 

5.  Diarrhea. — Several  varieties  of  this  ordinary  affection  of  infancy  have 
been  described,  but  an  elaborate  classification  seems  unnecessary,  since  many 
factors  both  in  a  causative  and  cura- 
tive way  are  common  to  the  various 
forms.  Three  or  four  movements  a 
day,  if  normal  in  consistency  and  in 
color,  need  excite  no  apprehension. 
If  the  passages  are  greenish  and  con- 
tain undigested  particles,  attention 
should  be  directed  to  the  feeding. 
Treatment:  To  remove  all  irritant 
matter  from  the  intestine  is  the  first 
feature  which  requires  attention.  A 
purge  with  castor  oil,  calomel,  or  a 
saline  should  be  given.  At  times  a 
high  injection  of  a  quantity  of  deci- 
normal  salt  solution,  with  or  without 
some  mild  astringent, — witch-hazel, 
for  example, — is  an  effective  adjunct 
to  catharsis.  When  a  thorough  evac- 
uation has  been  accomplished,  some 
preparation  of  opium  may  be  given  to 
lessen  peristaltic  activity.  During  the 
attack  the  diet  should  be  very  limited ; 
in  some  cases  nothing  but  very  moder- 
ate quantities  of  water,  plain  or  in  combination  with  egg-albumen  or  barley,  should 
be  administered  in  the  first  twenty-four  or  forty-eight  hours.  When  the  condition 
of  the  patient  warrants,  the  diet  should  be  gradually  increased.  Plenty  of  pure 
water  must  be  given.  If  diarrhea  continues  and  bids  fair  to  be  exhausting,  two  to 
four  drops  of  paregoric,  with  four  drops  of  aromatic  sulphuric  acid  or  gr.  iij  to  v 
bismuth  subnitrate,  may  be  tried.  The  paregoric  should  not  be  repeated,  how- 
ever, until  the  effects  of  the  first  dose  have  entirely  disappeared.  The  bismuth 
may  be  repeated  as  indicated. 

6.  Constipation. — The  term  constipation  in  young  children  signifies  any  delay 
beyond  the  normal  period  in  the  passage  of  fecal  matter.  Etiology:  Anatomi- 
cally the  formation  and  disposition  of  the  colon  predispose  to  constipation.  Its 
relative  length  is  greater  than  in  the  adult,  its  walls  are  relatively  weaker,  and 
their  physiological  activity  is  not  fully  developed.  Congenital  abnormalities,  such 
as  narrowing  of  the  lumen  of  the  gut,  are  rare  causes  in  infancy.  Among  the 
exciting  causes,  which  include  deficient  glandular  secretion,  excessive  perspira- 


FiG.    1033.  —  Glass 
Rectal  Syringe. 


Fig.   1034. — Rubber 
Rectal  Syringe. 


854  THE  PATHOLOGY   OF   THE  NEWLY  BORN. 

tion,  inflammatory  conditions,  and  frequent  purgations,  we  find  that  improper 
feeding  and  lack  of  general  muscular  tone  furnish  the  majority  of  cases.  The 
mother's  milk  may  be  deficient  in  fats,  while  artificially  prepared  foods  are  not 
only  lacking  in  the  proper  amount  of  fat,  but  are  also  often  too  easily  digested, 
leaving  but  little  residue  to  form  the  basis  of  a  proper  stool.  Too  great  a  quantity 
of  proteids  or  an  insufficient  fluid  supply  will  also  lead  to  constipation.  Rickets 
is  a  potent  cause.  Symptoms :  The  number  and  character  of  the  stools  in  each 
twenty-four  hours  give  the  most  reliable  information  concerning  the  alimentary 
processes.  In  the  newly  bom  one  or  even  two  or  three  stools  each  day  do  not 
preclude  the  existence  of  constipation  when  the  movements  are  drier  and  flrmer 
and  more  lumpy  than  normal  and  are  expelled  by  straining.  When  daily  stools 
do  not  occur  without  medicinal  or  mechanical  assistance,  other  symptoms  may 
arise,  as  flatulence,  distention  of  the  abdomen,  colicky  pains,  restlessness,  dis- 
turbed sleep,  and  even  high  fever,  convulsions,  and  much  prostration.  Hernia 
and  prolapsus  ani  may  be  resultant  phenomena.  Treatment:  The  attention  of  the 
mother  or  nurse  should  be  directed  to  the  formation  of  a  regular  habit ;  even  very 
young  infants  seem  to  appreciate  the  motive  of  being  placed  in  the  chair  at  certain 
daily  intervals.  The  method  of  feeding  should  be  investigated  and  the  cause  re- 
moved if  possible.  Constipation  may  be  due  to  the  presence  of  too  little  fat  or 
too  much  proteid  matter  in  the  food.  The  introduction  of  a  suppository  of  pure 
castile  soap  is  a  simple  and  usually  effective  way  of  causing  a  movement,  since  in 
most  cases  the  trouble  is  due  to  the  presence  of  a  rather  hard  fecal  mass  in  the  rec- 
tum. If  the  continued  use  of  the  soap  suppository  causes  irritation,  the  domestic 
resource,  a  cone  of  oiled  paper,  may  be  used.  The  prolonged  use  of  glycerin 
suppositories  may  cause  considerable  irritation  and  even  inflammation.  The 
habit  of  regular  movement  may  be  cultivated  by  giving  the  child  a  supposi- 
tory at  a  certain  hour  each  day.  If  it  becomes  necessary  to  give  an  enema, 
not  more  than  half  an  ounce  of  pure  castile  soap  and  water  should  be  given, 
since  the  rectum  in  young  children  is  relatively  small.  When  water  is  not 
effective,  the  injection  of  a  little  sweet  oil  may  be  promptly  successful.  When 
suppositories  or  enemata  are  ineffectual,  a  drachm  or  two  of  sweet  oil  by  the 
mouth  is  sometimes  useful.  Much  benefit  may  often  be  derived  from  the 
administration  of  fifteen  drops  of  cod-liver  oil  three  times  a  day.  An  effort 
should  be  made  to  regulate  the  bowels  by  attention  to  food  and  by  the  use  of 
suppositories,  and  by  dispensing  as  far  as  possible  with  the  use  of  laxative 
medicines.  Castor  oil  should  not  be  given  in  the  habitual  constipation  of 
infants.  If  medicine  becomes  necessary,  a  few  drops  of  the  fluid  extract  of 
cascara  sagrada  may  be  given,  or  a  little  milk  of  magnesia.  Massage  of  the 
abdomen  is  often  useful. 

7.  Intestinal  Obstruction. — The  majority  of  these  cases  occur  during  the  first 
year  of  life,  and  the  prompt  recognition  and  treatment  of  the  condition  are 
most  important.  Etiology:  In  the  newly  bom,  malformation — such  as  imperforate 
anus,  occlusion  of  the  rectum,  or  maldevelopment  of  any  portion  of  the  intestinal 
tract,  more  often  of  the  duodenum — plays  an  important  part.  During  the  first 
six  months  of  life  intussusception  is  responsible  for  one-half  of  the  cases.  Treat- 
ment: The  proper  treatment  of  intussusception  consists  in  efforts  to  reduce  the 
displacement  by  pressure  from  below.  Two  methods,  inflation  and  injection,  are 
employed.  Inflation  should  be  practised  under  an  anesthetic,  the  amount  of  air 
introduced  being  regulated  by  the  amount  of  tension  of  the  abdominal  walls. 
Injections  of  lukewarm  water  are  given,  the  buttocks  being  elevated  to  aid  the 
entrance  of  the  fluid  into  the  bowel.  Reduction  is  generally  followed  by  gurgling 
sounds  and  the  expulsion  of  flatus,  with  quick  relief  from  all  distressing  symp- 


GENERAL  POST-PARTUM  CONDITIONS.  855 

toms.     Laparotomy  must  be  resorted  to  at  times.      For  the  congenital  causes  of 
intestinal  obstruction  surgical  treatment  is  necessary. 

8.  Pneumonia. — (See  Acute  Infectious  Diseases,  page  808.) 

9.  Convulsions. — The  term  convulsions  is  here  employed  to  designate  the 
bodily  conditions  characterized  by  acute  seizures,  clonic,  rhythmic,  sometimes 
violent,  generally  involving  one  set  of  muscles,  or  the  entire  muscular  system, 
with  unconsciousness  as  a  usual  accompaniment.  They  occur  as  a  symptom  in 
a  great  variety  of  diseases,  but  here  only  those  occurring  in  infancy  will  be  con- 
sidered. Etiology:  Infancy  itself  is  the  great  predisposing  cause.  The  infant 
cerebrospinal  system  is  easily  impaired  and  deranged,  and  readily  loses  its 
equilibrium,  especially  during  the  period  of  its  most  active  development.  Some 
children  inherit  susceptible  nervous  temperaments.  In  older  children  rickets 
is  the  most  prominent  predisposing  cause.  Of  the  exciting  causes,  some  irritant 
in  the  alimentary  canal,  due  to  transitory  changes  in  the  mother's  milk,  or  to 
improper  food,  is  the  most  frequent  and  leads  to  gastric  or  intestinal  indigestion. 
The  irritant  may  produce  convulsions  reflexly,  but  authorities  are  now  practi- 
cally agreed  upon  the  adoption  of  the  toxic  theory  as  the  proper  explanation. 
Atelectasis,  meningitis,  and  meningeal  and  cerebral  hemorrhage  are  direct  causes. 
Dentition  is  an  extremely  rare  cause.  Retention  of  urine  and  phimosis  are  some- 
times directly  responsible.  Symptoms:  General  convulsions  do  not  differ  materi- 
ally from  ordinary  epileptic  seizures  so  far  as  the  infant's  appearance  is  concerned. 
In  some  cases  prodromal  signs  of  restlessness  and  irritability  may  give  warning, 
but  most  often  the  attack  comes  on  suddenly.  The  face  is  pale  or  cyanosed,  the 
head  is  thrown  back,  the  eyes  roll  or  are  staring,  the  hands  are  clenched  with 
thumbs  adducted  to  the  palms,  then  twitchings  of  the  eyelids  or  the  face  or  of  one 
extremity  are  soon  followed  by  clonic  movements  of  the  entire  body.  Foaming 
at  the  mouth  is  common,  the  heart  is  rapid  and  weak,  the  pulse  irregular,  res- 
piration embarrassed,  urine  and  feces  may  be  voided  involuntarily,  and  the  entire 
body  surface  is  covered  with  clammy  perspiration.  Gradually  the  convulsions 
cease  and  the  child  passes  into  a  sleep  or  stupor,  to  be  followed  in  most  cases 
by  one  or  more  convulsions.  Unilateral  convulsions  make  one  suspicious 
of  a  cranial  lesion,  while  those  occurring  with  fever  of  103°  to  106°  F.  are 
suggestive  of  the  onset  of  acute  infectious  disease.  Treatment:  This  is  first 
directed  to  the  controlling  of  the  spasms.  Baths  at  a  temperature  of  105° 
to  110°  F.,  given  for  from  five  to  fifteen  minutes,  are  the  raost  effective  means 
at  our  command.  In  infants  under  four  months  of  age  the  skin  is  tender  and 
plain  water  is  sufficient,  but  in  older  infants  mustard — a  handful  to  four  gallons 
of  water — will  enhance  the  effectiveness  of  the  baths.  In  severe  cases  the  temper- 
ature of  the  bath  should  be  increased  to  112°  or  115°  F.,  and  the  child  immersed 
for  at  least  ten  minutes.  Friction  of  the  entire  body,  but  particularly  to  the 
extremities,  should  be  performed.  After  the  bath  the  infant  should  be  wrapped 
in  a  warm  blanket  and  placed  on  its  right  side  to  relieve  the  overburdened 
right  heart.  An  ice-bag  to  the  head  and  hot  bottles  to  the  feet  are  always 
useful.  Chloroform  by  inhalation  is  necessar}^  at  times  in  older  children,  and 
chloral  hydrate  and  sodium  or  potassium  bromide  per  rectum  in  proper  doses 
are  useful  and  powerful  sedatives.  As  soon  as  the  convulsion  is  controlled  an 
enema  should  be  given  to  insure  a  thorough  action  of  the  bowels.  A  purge 
is  always  indicated,  and  castor  oil  is  the  best  of  that  class.  Up  to  the  age 
of  five  months  the  administration  of  one-half  teaspoonful  will  ordinarily  be 
followed  by  good  results.  If  there  is  much  prostration,  whisky  in  ten  to  thirty 
minim  doses  should  be  given  every  two  or  three  hours. 

10.  Infantile  Cachexia. — (See  Inanition,  page  840.) 


856  THE  PATHOLOGY  OF  THE  NEWLY  BORN. 

11.  Sudden  Death  of  the  Newly  Bom. — In  infants  who  present  no  visib'e 
external  changes  sudden  death  is  not  an  infrequent  occurrence.  The  excita- 
bility of  the  nervous  centers  in  the  young  and  their  violent  response  to  con- 
ditions incapable  of  serious  results  in  older  persons  tend  to  make  this  subject 
one  of  extreme  interest,  especially  in  a  medico-legal  way.  It  is  generally  due 
to  one  of  the  following  causes:  Asphyxia  occurs  from  over-lying  in  bed,  from 
particles  of  food  lodged  in  the  larynx,  or  from  an  enlarged  thyroid  gland  pressing 
upon  the  trachea  or  pneumogastric  nerve.  Of  the  infants  who  are  bom  in  a  state 
of  asphyxia  and  respond  to  methods  of  resuscitation,  about  4  per  cent,  die  within 
three  days  after  birth  and  autopsy  reveals  a  condition  of  atelectasis.  Convul- 
sive disorders:  Seven  per  cent,  of  sudden  deaths  are  referred  to  this  cause.  In 
infants,  in  nine  cases  out  of  ten,  convulsions  are  due  to  some  irritant  in  the 
alimentary  canal;  in  older  children  rachitis  is  the  great  underlying  cause. 
Cranial  hemorrhage  is  also  a  cause  of  convulsions,  but  children  rarely  die  sud- 
denly from  it.  Infantile  cachexia:  This  is  one  of  the  common  causes,  and  heart 
failure  is  the  most  probable  cause  of  death,  since  real  lesions  are  rarely  found  at 
post-mortem  examination.  Internal  hemorrhage:  Hemorrhage  into  the  brain, 
lungs,  pleura,  stomach,  intestines,  or  any  of  the  abdominal  organs  gives  symptoms 
of  sudden  collapse  quickly  followed  by  death.  This  occurs  very  early  in  life, 
the  infant  seemingly  being  affected  by  the  sudden  change  from  intrauterine  to 
extrauterine  existence.  Pulmonary  congestion:  This  may  complicate  any  sudden 
and  great  rise  of  temperature  and  cause  death  in  a  few  hours.  In  the  acute 
infectious  diseases,  particularly  bronchopneumonia,  a  certain  number  of  infants 
are  overwhelmed  by  the  intensity  of  the  intoxication.  As  other  causes  of 
sudden  death  may  be  mentioned  congenital  malformations  of  the  principal 
bodily  organs,  such  as  hernia,  hydrocephalus,  patent  foramen  ovale  or  ductus 
arteriosus,  defects  in  the  ventricular  septum,  diaphragmatic  hernia,  narrowing 
or  occlusion  of  the  stomach  or  intestines,  imperforate  anus,  and  abnormalities 
of  the  kidney  and  ureter. 

12.  Medication  of  the  Newly  Bom. — The  infant  is  often  treated  through  the 
mother,  but  the  amount  of  a  drug  which  reaches  the  former  through  the  milk 
is  now  believed  to  be  too  insignificant  to  produce  therapeutic  results.  It  there- 
fore becomes  necessary  at  times  to  administer  medicines  directly  to  the  newly 
bom.  Stimulants:  These  have  a  very  wide  field,  being  indicated  in  the  nu- 
merous severe  septic  affections  as  well  as  in  prematurity  and  general  debility. 
The  dose  is  i  to  3  drops  of  whisky  hourly,  increased  in  septic  cases.  Seda- 
tives :  In  case  of  colic  or  other  pain  which  resists  attempts  to  regulate  the 
diet,  etc.,  a  mild  opiate  may  be  given  (paregoric,  i  to  5  ^).  The  bromides 
and  chloral  are  useful  per  rectum.  Stomachics:  For  indigestion,  flatulence, 
colic,  etc.,  carminatives  are  indicated,  with  small  doses  of  calomel  (yV  grain 
every  three  hours).  Antacids  are  also  useful  (soda,  magnesia),  as  also  is 
pepsin.  Laxatives:  When  mild  remedies  like  sugar  will  not  suffice,  calomel, 
castor  oil,  and  cascara  sagrada  are  most  effective.  Diuretics:  Sweet  spirits 
of  niter  is  the  remedy  usually  chosen  to  produce  diuresis  in  the  newly  bom. 
Local  remedies:  The  toxic  antiseptics  should  be  used  well  diluted,  if  at  all  {e.  g., 
corrosive  sublimate  i  :  10,000).  Boric  acid  is  preferable,  as  a  rule,  to  the 
poisonous  drugs.  Counterirritation  is  practised  chiefly  for  colic  and  vomiting, 
in  the  form  of  a  spice  poultice  over  the  abdomen. 


PART    TEN. 

Obstetric  Surgery* 


(A)  INTRODUCTION. 

I.  PREPARATIONS  FOR  OPERATION.    (Page  860.)     II.  DECINORMAL  SALINE 

SOLUTION  INJECTIONS.  (Page  861.)  III.  ANESTHESIA  IN  OBSTET- 
RICS. (Page  865.)  IV.  POSTURE  IN  OBSTETRICS.  (Page  868.)  V. 
VAGINAL  EXAMINATION.  (Page  879.)  VI.  DIGITAL  EXPLORATION 
OF  THE  UTERUS.  (Page  880.)  VII.  VULVAL  DOUCHE.  (Page  881.) 
VIII.  VAGINAL  IRRIGATION.  (Page  881.)  IX.  INTRAUTERINE  IRRI= 
GATION.  (Page  882.)  X.  VAGINAL  TAMPON.  (Page  884.)  XL  UTER= 
INE  TAMPON.  (Page  885.)  XII.  PASSING  THE  CATHETER.  (Page 
887.) 

(B)  OPERATIONS  PREPARATORY  TO  DELIVERY. 

II.  ARTIFICIAL  RUPTURE   OF   MEMBRANES.     (Page  887.)     II.  INDUCTION 

OF  ABORTION  AND  PREMATURE  LABOR.  (Page  888.)  III.  MANUAL 
DILATATION  OF  THE  CERVIX.  (Page  895.)  IV.  INSTRUMENTAL 
DILATATION  OF  THE  CERVIX.  (Page  902.)  V.  MANUAL  AND  IN= 
STRUMENTAL  DILATATION  OF  THE  VAGINA  AND  VULVA.  (Page 
906.)     VI.  INCISIONS  OF  CERVIX,  VAGINA,  AND  VULVA.     (Page  907.) 

VII.  CORRECTION  OF  FAULTY  POSTURES,  MALPOSITIONS,  AND 
MALPRESENTATIONS.  (Page  911.)  VIII.  VECTIS.  (Page  915.)  IX. 
FILLET.  (Page  915.)  X.  REPOSITION  OF  PROLAPSED  SMALL  PARTS, 
FOOT  AND  CORD.  (Page  916.)  XL  VERSION.  (Page  919.)  XII. 
PELVIOTOMY.  (Page  936.)  XIII.  SYMPHYSEOTOMY.  (Page  937.) 
XIV.  EMBRYOTOMY  IN  GENERAL.  (Page  942.)  XV.  PERFORATION. 
(Page  944.)  XVI.  RACHIDOTOMY.  (Page  946.)  XVII.  CRANIOCLASM. 
(Page  947.)  XVIII.  CEPHALOTRIPSY.  (Page  951.)  XIX.  DECAPITA= 
TION.  (Page  955.)  XX.  EVISCERATION.  (Page  960.)  XXI.  AMPU= 
TATION  OF  EXTREMITIES.  (Page  961.)  XXII.  CLEIDOTOMY.  (Page 
961.)      XXIII.     SPONDYLOTOMY.     (Page  963.) 

(C)  OPERATIONS  FOR  DELIVERY. 

III.  EXPRESSION    OF    THE  FETUS,    EXPRESSIO    FCETUS.     (Page  963.)     II. 

FORCIBLE  DELIVERY,  ACCOUCHEMENT  FORCE.  (Page  964.)  III. 
MANUAL  EXTRACTION  OF  THE   FORE=COMING  HEAD.     (Page  965.) 

IV.  SHOULDER  EXTRACTION  IN  HEAD=FIRST  LABORS.     (Page  966.) 

V.  BREECH  EXTRACTION.  (Page  968.)  VI.  EXTRACTION  OF  THE 
AFTER=COMING    HEAD.      (Page   974.)      VII.   FORCEPS.       (Page   983.) 

VIII.  SLING  OR  SOFT  FILLET.  (Page  1007.)  IX.  BLUNT  HOOK.  (Page 
1009.)  X.  CROCHET.  fPage  1010.)  XL  EXTRACTION  OF  THE  FETUS 
MUTILATED  BY  EMBRYOTOMY.  (Page  1011.)  XII.  C/ESAREAN  SEC- 
TION. (Page  1011.)  XIII.  ABDOMINAL  HYSTERECTOMY.  (Page 
1016.)  XIV.  PORRO  C/ESAREAN  SECTION.  (Page  1020.)  XV.  VAGI= 
NAL  C/ESAREAN  SECTION.  (Page  1022.)  XVI.  POST=MORTEM 
C/ESAREAN  SECTION.  (Page  1025.)  XVII.  DELIVERY  OF  PLACENTA 
AND  MEMBRANES.  (Page  1025.)  Crede's  Method.  Dublin  Method. 
Digital  Extraction.  Manual  Extraction.  Instrumental  Extraction.  Curet= 
tage. 

(D)  OPERATIONS  FOR  THE  CORRECTION  OF  INJURIES. 

IV.  CELIOTOMY  FOR  RUPTURE  OF  THE  UTERUS.     (Page  1031.)      II.  CELIO= 

TOMY  FOR  SEPSIS  OF  THE  UTERUS.  (Page  1032.)  III.  REPAIR  OF 
INJURIES  TO  CERVIX,  VAGINA,  RECTUM,  PERINEUM,  CLITORIS. 
(Page  1032.) 


(A)  INTRODUCTION. 

The  subject  of  obstetric  surgery  falls  naturally  into  three  divisions:  The  fi-rst 
embraces  operations  preparatory  to  delivery,  such  as  the  premature  induction  of 
labor;  removal  of  the  barrier  of  the  cervix;  correction  of  faulty  presentations, 
attitudes,  and  positions;  increasing  the  size  of  the  pelvis  by  symphyseotomy  or 
diminishing  the  size  of  the  fetus  by  craniotomy  or  cutting  operations  on  the 
trunk.  The  second  division  includes  operations  for  delivery,  such  as  expres- 
sion, manual  and  forceps  extraction,  Cocsarean  section,  and  various  methods  of 
placental  delivery.  In  the  third  division  fall  the  various  operations  for  the 
correction  or  repair  of  injuries  produced  during  labor. 

In  considering  the  subject  of  obstetric  surgery,  my  aim  will  be  to  give  briefly 
and  concisely  an  account  of  the  best  method  of  dealing  with  the  various  forms 
of  dystocia,  and  an  effort  will  be  made  to  give  in  condensed  form  the  gist  of 
modern  scientific  teaching  and  of  my  own  experience  in  each  case.  The  dis- 
cussion of  unconfirmed  theories,  disputed  points,  and  measures  of  doubtful  ex- 
pediency will  be  avoided  as  unsuited  to  a  work  of  this  character. 

Labor  is  a  physiological  process,  and  in  normal  cases  the  less  interference 
the  better.  No  consideration  of  time  or  convenience,  or  even  the  entreaties  of 
the  patient  or  her  friends,  should  be  used  as  an  excuse  for  interference  unless 
such  interference  is  distinctly  indicated  in  the  interest  of  mother  or  child. 
Various  abnormal  conditions  and  causes,  however,  into  which  it  is  not  now 
necessary  to  enter,  may  render  operative  interference  not  only  justifiable  'but 
imperative. 

Primum  non  nocere  is  a  principle  not  always  easy  to  impress  upon  the  under- 
graduate student.  The  student  in  his  two  or  four  weeks'  course  in  practical 
obstetrics  may  possibly  witness  many  obstetric  operations  and  naturally  draw 
the  conclusion  that  interference  in  cases  of  confinement  is  of  common  occurrence, 
when  we  desire  to  impress  upon  the  student's  mind  quite  another  picture. 
With  a  false  impression  the  young  physician  enters  upon  his  practice,  and 
one  unnecessary  operation  leads  often  enough  to  a  long  train  of  misfortunes. 
Unfortunately  we  see  many  examples  of  the  foregoing.  A  primipara,  for  in- 
stance, has  been  in  labor  for  twelve  hours;  the  membranes  have  ruptured  several 
hours  previously;  the  head  rests  upon  a  rigid  pelvic  floor;  which  latter  delays 
the  second  stage;  the  fetal  heart  is  good;  the  mother  is  in  excellent  condition, 
and  as  yet  there  is  no  danger  of  damage  to  the  soft  parts,  as  the  head  has  only  just 
reached  the  pelvic  outlet ;  there  is,  therefore,  no  indication  for  interference.  A  hur- 
ried low-forceps  operation  is  performed ;  a  third  degree  laceration  of  the  pelvic  floor 
results;  a  hurried  operation  for  repair  is  done,  which  in  the  absence  of  proper 
assistance  and  ligatures  gives  a  bad  result.  What  follows?  A  subsequent  opera- 
tion must  be  performed  by  an  expert,  and  in  the  mean  time,  and  possibly  after 
the  second  operation,  should  it  too  fail,  the  patient  is  doomed  to  rectal  inconti- 
nence ahd  becomes  an  exile  from  society,  and  all  because  in  the  first  instance 
in  the  absence  of  a  positive  indication,  a  "hannless  low-forceps  operation"  was 

859 


860  OBSTETRIC  SURGERY. 

performed.  Still  another  clinical  picture  presents  itself.  A  pelvic  presentation 
occurs  in  a  multipara.  One  foot  prolapses  and  appears  at  the  vulva.  Mother 
and  fetus  are  in  perfect  condition.  There  is  positively  no  indication  for  inter- 
ference, but  the  temptation  is  too  great.  In  order  to  facilitate  delivery,  the 
attending  physician  seizes  and  makes  traction  on  the  prolapsed  leg.  What  re- 
sults? The  head,  as  well  as  one  or  both  arms,  becomes  extended.  Delay  in  the 
delivery  of  the  extended  arms  and  head  causes  death  of  the  fetus.  The  difficult 
extraction  results  in  deep  laceration  of  the  cervix  extending  into  the  folds  of 
the  broad  ligament.  Severe  hemorrhage  follows.  A  hasty  tamponade  of  uterus 
and  vagina,  not  under  aseptic  precautions,  results  subsequently  in  severe  en- 
dometritis and  parametritis.  What  is  the  termination  of  such  a  case?  Death 
of  the  child,  and  the  mother  left  with  crippled  pelvic  organs,  perhaps  for  life, 
all  from  an  attempt  to  facilitate  the  progress  of  labor  by  traction  upon  a  pro- 
lapsed leg. 

The  student  cannot  have  too  often  repeated  to  him  the  statement  that 
obstetric  operations  of  any  kind  should  be  undertaken  only  in  the  presence 
of  a  positive  indication;  that  even  what  are  apparently  innocent  operative  pro- 
cedures in  obstetrics  may  terminate  in  tragedies.  The  more  impressed  the 
student  is  with  the  full  meaning  of  the  term  primum  non  nocere  during  his 
residence  in  the  medical  school  and  maternity,  the  more  conservative  and  the 
better  accoucheur  will  he  become  in  his  private  practice,  the  better  the  fate  of 
the  mother  and  child  entrusted  to  him,  and  the  better  his  professional  reputa- 
tion. 


I.  PREPARATIONS  FOR  OPERATION. 

Patient. — Many  obstetric  operations  may  be  performed  with  the  patient  placed 
across  the  bed  in  the  lithotomy  position,  the  buttocks  being  drawn  to  the  edge. 
The  flexed  thighs  are  either  held  or,  better,  confined  with  a  sheet  or  canvas  crutch. 
Rubber  sheeting  or  a  Kelly  pad  and  a  pail  are  used  for  drainage  (Fig.  1048). 
It  is  far  better,  however,  in  private  practice,  to  improvise  an  operating  table 
by  pressing  into  use  the  kitchen,  dining-room,  or  other  table.  This  should  be 
covered  with  an  old  blanket  and  a  clean,  freshly  laundered  bed-sheet,  and  a 
Kelly  pad  or  a  rubber  sheet  placed  at  the  foot  to  drain  into  a  pail  or  foot-tub. 
The  patient  should  be  anesthetized  in  bed  and  afterward  placed  upon  the  table 
in  the  lithotomy  position,  with  thighs  held  in  flexed  position  by  a  twisted 
sheet  under  the  shoulders  or  a  Clover  crutch  (Fig.  1079).  The  rectum  must 
have  been  emptied  by  an  enema.  The  external  genitals  should  be  scrubbed 
with  soap,  brush,  and  warm  water.  For  all  intrauterine  or  cutting  operations 
the  pubes  and  vulva  should  be  shaved.  A  catheter  should  be  passed  and  a 
final  scrubbing  with  a  sublimate  solution  (i  :  2000)  or  i  per  cent,  lysol  performed. 
The  immediate  field  of  operation  should  be  surrounded  with  sterile  towels. 
The  vagina  should  be  carefully  washed  out,  before  all  intrauterine  operations, 
with  a  I  per  cent,  lysol  or  creolin  solution.  This  should  be  done  with  the 
fingers,  a  cotton  swab,  or  a  jeweler's  brush,  never  with  a  stiff  brush,  which 
would  injure  the  vaginal  mucous  membranes. 

Instruments  and  Dressings. — The  antiseptic  agents  used  in  obstetrical  practice 
are  the  same  as  those  used  in  general  surgery.  Heat  is  the  most  useful  and  easily 
applied  means  for  making  dressings  and  instruments  sterile.  Dry  heat  is  the 
least  convenient  form  to  use,  since  it  takes  longer  to  accomplish  its  purpose  than 
does  moist  heat  and  is  slow  in  penetrating  to  the  interior  of  a  bundle  of  dressings. 


DECINORMAL  SALINE  SOLUTION  INJECTIONS.  861 

Moist  heat  may  be  used  as  steam  at  ordinary  or  increased  pressure,  or  in  the 
form  of  boiling  water.  Superheated  steam  does  not  penetrate  much  better  than 
dry  heat.  Many  hospitals  use  an  instrument  which  subjects  its  contents  to 
steam  at  about  250°  F.  (121°  C.)  at  15  pounds  pressure,  and  this  is  found  very 
efficacious  for  dressings  and  other  materials.  Boiling  in  plain  water,  or,  better, 
in  water  to  which  about  i  per  cent,  of  sodium  carbonate  or  bicarbonate 
has  been  added,  is  an  exceedingly  convenient  method  of  sterilizing  instru- 
ments or  anything  which  will  stand  the  treatment.  The  addition  of  the  soda 
prevents  rusting  and  shortens  the  time  necessary  for  boiling.  Five  minutes  of 
active  ebullition  is  enough.  The  soda  should  be  chemically  pure;  otherwise  sub- 
stances might  be  present  which  would  injure  the  instruments.  In  private  practice 
obstetric  instruments  should  be  contained  in  canvas  cases  (page  468)  or  pinned 
in  towels  before  boiling.  They  are  then  brought  to  the  operating  table  on  a 
dish  without  removing  the  towel  and  taken  directly  from  the  towel  for  use  in 
the  given  operation.  Trays  and  antiseptic  solutions  for  instruments  are  thus 
dispensed  with. 

Operator. — (See  Asepsis  in  Obstetrics,  page  148.) 


11.  DECINORMAL  SALINE  SOLUTION  INJECTIONS. 

INFUSION,  ENTEROCLYSIS,  HYPODERMOCLYSIS. 

On  account  of  the  great  importance  of  this  resource  in  obstetrics  and  the 
number  of  conditions  for  which  it  maybe  indicated — including  eclampsia,  hemor- 
rhage, and  sepsis — I  have  thought  it  advisable  to  devote  a  special  section  to 
the  general  principles  and  technique  of  the  various  methods  of  exhibiting  the 
saline  solution. 

Preparation  of  the  Solution. — The  decinormal  saline  solution  consists,  roughly 
speaking,  of  a  drachm  of  salt  (sodium  chloride)  to  a  pint  of  water,  but  this 
simple  formula  has  been  modified  in  various  ways.  Water  alone,  provided  that 
it  is  not  distilled,  may  replace  the  salt  solution  in  emergencies;  and  any  propor- 
tion of  salt  will  answer  which  does  not  exceed  three  times  the  proportion  nor- 
mally contained  in  the  blood.  As  a  matter  of  fact,  the  solutions  in  use  varv' 
from  yV  per  cent,  to  jjj  per  cent.  To  prepare  a  solution  with  accuracy,  forty-six 
grains  are  added  to  a  pint  of  water,  but  in  emergencies  a  small  teaspoonful, 
not  heaped  up,  will  suffice.  After  the  solution  has  been  prepared  it  should 
be  boiled  and  filtered.  While  the  saline  solution  is  supposed  to  be  freshly  pre- 
pared at  the  time  of  use,  it  is  necessary  in  hospital  practice  to  have  it  constantly 
on  hand,  and  the  custom  which  generally  prevails  is  to  prepare  a  concentrated 
solution  which  can  be  diluted  as  required.  The  solution  must  be  exhibited  at 
a  certain  temperature.  While  100°  F.  is  the  conventional  temperature,  some 
obstetricians  prefer  105°  to  110°  F.  as  representing  a  gain  in  stimulating  proper- 
ties. 

Rectal  Infusion. — From  four  ounces  to  a  pint  and  a  half  of  the  decinormal 
salt  solution,  at  a  temperature  of  110°  to  120°  F.,  should  be  kept  in  the  bowel 
continuously.  Any  of  the  usual  rectal  tubes  may  be  used,  but  a  soft-rubber 
catheter  attached  to  the  tube  of  a  fountain  syringe  usually  causes  the  least 
irritation.  The  patient  may  be  placed  in  the  dorsal  or  lateral  position,  and 
it  is  convenient  to  have  the  buttocks  project  a  little  over  the  edge  of  the  bed. 
I  have  found  that  the  left  lateral  posture  with  elevation  of  the  hips  favors 
retention  of  the  solution,  and  is  least  objectionable  to  the  patient  (Fig.   105 1). 


862 


OBSTETRIC  SURGERY. 


WfX' 


Indications:  As  a  preventive  or  curative  measure  in  cases  of  shock,  especially  of 
shock  from  hemorrhage. 

Intra-arterial  Infusion. — The  radial  artery  is  the  vessel  usually  chosen  for 
infusion,  on  account  of  its  accessibility.  The  skin  is  scratched  over  the  artery 
as  a  guide,  the  limb  is  elevated,  and  a  tourniquet  is  applied  to  the  upper  arm. 
The  incision  is  i  or  2  inches  (2.5  or  5  cm.)  long  and  crosses  the  artery  obliquely. 
The  vessel  is  carefully  isolated,  divided,  and  ligated  at  the  central  end.  A 
cannula  is  then  inserted  into  the  peripheral  end  and  tied  in  while  infusion  is  pro- 
ceeding. The  tourniquet  is  then  loosened,  and  after  the  infusion  is  completed 
the  cannula  is  withdrawn  and  the  peripheral  end  of  the  vessel  is  also  ligated. 
This  form  of  intervention  is  too  radical  and  complicated  for  routine  use. 

Intravenous  Infusion.  —  Indica- 
tions.— The  indications  for  intraven- 
ous infusion  are  similar  to  those  of 
other  methods  of  exhibiting  the  salt 
solution.  Generally  speaking,  it  is 
the  typical  method,  the  others  hav- 
ing a  more  limited  field.  In  sepsis 
and  eclampsia  or  toxemia  in  general, 
it  is  sometimes  the  custom  to  conjoin 
phlebotomy  with  infusion.  The  in- 
cision made  for  the  cannula  will 
suffice  for  the  escape  of  the  blood, 
which  should  average  about  a  pint. 
In  certain  cases  venesection  is  carried 
out  in  one  arm  and  infusion  in  the 
other,  the  operations  being  syn- 
chronously performed.  The  reaction 
against  the  teaching  of  the  past,  that 
entrance  of  air  into  a  vein  is  a  fatal 
accident,  is  believed  to  be  unwise. 
Fatalities  certainly  have  occurred, 
and  it  is  well  to  take  all  precautions. 
Experiments  on  animals  show  that 
the  rational  treatment  of  air  in  the 
veins  is  the  persistence  in  the  process 
of  infusion  at  110°  F.,  with  artificial 
respiration. 

Techniqtie. — The  solution  should 
be  contained  in  a  glass  irrigating  jar 
having  a  capacity  of  five  pints  or  more.  The  flow  should  never  exceed  the  rate 
of  a  pint  in  five  minutes.  The  jar  should  be  provided  with  a  bath  thermometer, 
and  an  apparatus  for  raising  and  lowering  it  to  any  desired  height.  While 
infusion  is  in  progress  it  is  well  to  wrap  the  irrigating  jar  in  a  large,  hot,  sterile 
towel  to  assist  in  maintaining  the  requisite  degree  of  heat.  This  outfit  is 
required  because  intravenous  infusion  is  almost  a  routine  procedure  at  the 
present  day.  In  emergencies  a  fountain  syringe  may  be  used,  the  infusion 
being  made  as  hot  as  the  hand  will  bear.  The  tubing  of  the  irrigating  jar 
is  fitted  with  a  transfusion  cannula  (Fig.  1038)  or  the  glass  tube  of  a 
medicine-dropper  may  be  used  as  a  cannula.  The  operation  is  preceded  by 
the  application  of  a  tourniquet  to  distend  the  veins.  The  most  conspicuous 
vein  should  then  be  chosen,  and  this,  as  a  rule,  is  the  median  basilic.     A  cuta- 


FiG.     1035.  —  Colon     Irrig.^tion 
Double  Catheter. 


DECTNORMAL  SALINE  SOLUTION  INJECTIONS. 


863 


neous  incision  is  made  of  sufficient  length  to  expose  about  half  an  inch  (1.25  cm.) 
of  the  vein,  which  is  then  isolated  and  raised  from  the  wound  (Fig.  1036).  The 
vessel  is  then  tied  with  fine  catgut  as  low  down  as  possible  and  a  second  ligature 
is  placed  high  up,  ready  to  be  knotted  when  desired.  Half  of  the  circumfer- 
ence of  the  vein  is  now  divided  with  scissors,  the  incision  being  just  above 
the  knotted  ligature.  The  cannula  with  its  stream  of  running  water  is  now 
inserted  as  far  as  possible  into  the  incision,  with  point  directed  toward  the  heart, 
and  the  second  ligature  knotted  to  retain  the  instrument  in  place.  The  knot 
should  be  a  bow,  in  order  that  the  ligature  shall  be  only  temporary.  After 
the  cannula  is  removed  the  same  ligature  may  be  used  for  the  purpose  of  tying 
the  central  end  of  the  exposed  vein.  After  application  of  the  temporary  liga- 
tures the  tourniquet  should  be  re- 
moved. Kemp  emphasizes  the  fact 
that  a  very  common  mistake  of  the 
beginner  is  neglecting  to  remove  the 
tourniquet  before  proceeding  with 
the  infusion;  under  these  circum- 
stances the  increase  in  intravenous 
pressure  will  burst  the  vein  sooner  or 
later. 


V 


Fig.  1036. — Infusion  of  Sal- 
ine Solution  into  a  Vein 
OF  THE  Arm. 


Fig.  1037. — Same    as    Fig. 
1036,   BUT  Enlarged. 


Fig.  103S. — Can- 
nula for  In- 
travenous In- 
fusion. 


Enteroclysis. — No  special  apparatus  is  required,  as  the  single-  or  double-cur- 
rent irrigation  tubes  will  suffice.  Assuming  that  the  solution  should  have  a  tem- 
perature in  the  intestine  of  at  least  100°  F.,  it  should  be  exhibited  one  or  two 
degrees  higher  to  allow  for  slight  cooling.  The  dorsal  position  appears  to  be  the 
best,  the  hips  being  slightly  elevated.  It  is  well  to  let  the  solution  escape  while 
the  tube  is  being  inserted.  A  number  of  double-current  rectal  tubes  have  been 
devised  for  the  purpose  of  continuous  exhibition  of  liquids.  There  are  other 
advantages  connected  with  the  double  system,  for  the  temperature  as  well  as 
the  quantity  is  under  control.  Continuous  irrigation  may  easily  be  maintained 
for  an  hour  or  more,  and  the  patient  may  remain  entirely  passive.     A  double- 


8G4 


OBSTETRIC  SURGERY. 


current  irrigator  may  be  improvised  as  follows,  if  the  operator  has  no  special 
delivery  tube.  Two  catheters  of  different  caliber  should  be  so  fastened 
side  by  side  that  the  tip  of  the  smaller  instrument  projects  an  inch  or  two 
beyond  the  larger,  and  above  it,  so  that  the  inflow  may  be  on  the  higher  level. 
These  catheters  should  be  made  to  pass  through  a  perineal  pad  or  substitute 
before  insertion  into  the  bowel.  The  escape  tube  is  the  larger,  for  with  mucus, 
etc.,  it  must  carry  away  more  than  enters  through  its  smaller  fellow.  Dr. 
R.  C.  Kemp,  whose  valuable  monograph  *  I  have  freely  consulted  in  the  prepara- 
tion of  this  section,  has  devised  a  double-current  irrigator  which  is  the  result 
of  much  study  and  experience  in  this  department  of  therapeutics  f  (Fig-  1035)- 
Indications. — In  shock,  whether  post-operative  or  following  hemorrhage,  irri- 
gation is  so  managed  that  the  patient  has  a  pint  or  a  quart  of  infusion  in  the  bowel 
at  any  given  moment.  Continuous  irrigation,  maintained  for  a  considerable  period, 
is  especially  indicated  in  the  toxemia  of  pregnancy.  (Page^2  99.)  The  hot  solution 
(i  10°  F.  to  1 20°  F.)  is  advocated  in  these  cases.  While  enteroclysis  has  but  few  in- 
dications in  obstetrical  practice,  by 
reason  of  the  greater  excellence  of 
hypodermoclysis  and  infusion,  it  can 
nevertheless  be  employed  to  a  con- 
siderable extent  by  practitioners 
who  are  unfamiliar  with  the  other 
methods,  or  who  lack  the  necessary 
apparatus  for  their  performance. 

Hypodermoclysis. — This  method 
of  exhibiting  the  salt  solution  con- 
sists in  its  injection  into  the  subcu- 
taneous cellular  tissue.  Indications: 
Since  hypodermoclysis  increases  the 
quantity  of  fluid  in  the  vessels,  there- 
by making  good  any  deficit,  as  well 
as  acting  as  a  circulatory  stimulant ; 
and  since  it  promotes  the  action  of 
the  emunctories,  and  both  dilutes 
and  expels  toxic  substances,  it  is 
naturally  indicated  in  obstetrical 
practice  in  the  pregnancy  kidney  and 
eclampsia,  in  post-partum  hemor- 
rhage, shock,  and  sepsis.  Rnteroclysis  is  a  valuable  adjuvant  to  hypodermoclysis, ' 
either  during  or  after  the  performance  of  the  latter.  Dangers:  The  little  operation 
required  for  this  purpose  is  simple,  but  by  no  means  entirely  free  from  danger. 
Sloughing  has  followed  hypodermoclysis  beneath  the  female  breast.  The  neces- 
sary precautions  in  injecting  the  saline  solution  beneath  the  skin  comprise  avoid- 
ance of  overdistending  the  tissues  by  too  much  liquid  or  too  great  rapidity  of  flow, 
and  manipulation  of  the  apparatus  in  such  a  manner  that  no  air  is  able  to  enter 
the  tissues.  Site  of  Injection:  The  iliolumbar  site  {i.  e.,  the  space  between  the 
crest  of  the  ilium  and  the  lower  border  of  the  ribs)  possesses  natural  advantages 
as  the  site  of  injection.  The  patient  may  thereby  retain  the  dorsal  position 
and  have  the  free  use  of  all  her  limbs.  Submammary  injections  are  also  useful. 
In  shock  or  hemorrhage  it  may  be  necessary  to  give  injections  in  more  than 
one  locality.     Technique:  As  a  general  rule,  from  4  to  8  ounces  constitute  a 

*  "  Enteroelysis,  Hypodermoclysis,  and  Infusion." 
top.  cit.,  and  "Medical  Record,"  July  24,  1S97. 


Fig.  10,^9. — Subcutaneous  Infusion  of  Sa- 
line Solution  into  Both  Breasts  (Hypo- 
dermoclysis). 


ANESTHESIA    IN   OBSTETRICS.  865 

single  injection  in  hypodermoclysis.  The  solution  to  employ  is  the  ordinary 
decinormal  formula.  The  technique  of  hypodermoclysis  is  as  follows:  The  appa- 
ratus required  is  simple,  consisting  of  a  fountain  syringe  and  an  aspirating 
or  hypodermic  needle  (Fig.  1039).  If  an  ordinary  hypodermic  needle  is  used, 
the  bag  of  the  fountain  syringe  must  be  raised  to  the  height  of  from  4  to  6 
feet,  because  of  the  increased  resistance  of  the  fine  lumen;  and,  generally  speak- 
ing, the  larger  the  needle,  the  lower  the  pressure  required.  Much  time  is  wasted 
if  a  hypodermic  needle  is  used.  The  average  height  to  hang  the  bag,  if  a 
medium-sized  aspirator  is  used,  is  two  or  three  feet,  depending  on  the  rapidity 
of  the  flow.  The  fountain  syringe  and  its  tube,  together  with  the  needle  used, 
should  all  be  sterilized  by  boiling,  and  the  bag  should  contain  more  water  than 
is  injected  lest  air  enter  the  in-flowing  stream.  The  fluid  should  flow  freely 
from  the  needle  as  the  puncture  is  made.  The  same  precautions  are  to  be  used 
as  in  any  hypodermic  injection  in  regard  to  the  introduction  of  the  needle.  If 
more  solution  is  needed, — and  as  much  as  a  pint  may  be  employed  with  benefit 
in  some  cases  of  hemorrhage, — it  should  be  injected  in  divided  quantities  into  dif- 
ferent localities  (Fig.  1039).  The  temperature  of  the  solution  should  be  about  105° 
F.  if  a  large  needle  is  used,  but  at  least  five  degrees  higher  if  the  small  hypo- 
dermic needle  is  employed,  since  fully  that  amount  of  heat  will  be  lost  with  a 
fine  needle.     Local  anesthesia  may  be  applied  before  the  puncture,  if  desired. 


III.  ANESTHESIA  IN  OBSTETRICS. 

I.  During  Labor. — Choice  between  Chloroform  and  Ether. — The  rela- 
tive advantages  of  chloroform  and  ether  are  very  different  when  it  is  desired 
to  induce  analgesia  after  the  beginning  of  labor.  Here  two  factors  contribute 
to  increase  the  safety  of  chloroform.  They  are:  First,  the  stimulating  effect  of 
the  labor  pains  upon  cardiac  innervation;  second,  the  "physiological  anesthesia" 
attendant  upon  cerebral  congestion  induced  b\'-  the  bearing-down  efforts.  The 
first  factor  helps  to  prevent  chloroform  syncope,  and  the  second  to  diminish 
the  amount  of  chloroform  required.  It  is  nevertheless  true  that  the  safety 
of  chloroform  in  labor  is  relative,  not  absolute,  and  that  fatal  cases  have  been 
recorded.  Its  prolonged  administration — e.  g. ,  when  commenced  early  in  labor — 
is  not  only  injurious  to  the  mother,  but,  as  recent  observations  have  shown, 
is  likely  to  be  fatal  to  the  child.  Ether  is  used  by  a  few  obstetricians  as  an 
analgesic  during  labor.  It  has  been  found  that  most  of  the  objections  to  its 
use  have  little  force,  or  have  been  due  to  its  improper  administration,  and 
for  six  years  past  I  have  used  it  almost  to  the  exclusion  of  chloroform  in  both 
normal  labor  and  obstetric  surgery. 

Indications. — The  most  common  indication  for  anesthesia  is  unusual  severity 
of  the  pains.  If  the  labor  is  long  and  the  pains  are  abnormally  severe,  its  use 
is  justifiable  on  the  ground  of  humanity  and  to  diminish  the  shock  attendant 
upon  severe  and  prolonged  suffering.  The  administration  of  the  anesthetic, 
however,  should  be  delayed  as  long  as  practicable  and  confined  principally 
to  the  second  stage.  An  anesthetic  is  frequently  useful  in  aiding  the  progress 
of  labor,  especially  in  the  case  of  nervous  and  sensitive  women  who  are  badly 
affected  by  the  pains,  and  in  cases  in  which  the  contractions,  while  very  painful, 
have  but  little  power  and  in  which  the  uterus  does  not  relax  between  the  pains. 
In  cases  like  the  above,  in  which  the  reflex  influence  of  the  pains  delays  the 
progress  of  labor,  superficial  anesthesia  during  the  pains  is  frequently  very 
55 


866 


OBSTETRIC  SURGERY. 


useful.  Anesthesia  in  the  second  stage  will  often  serve  to  induce  timid  and 
nervous  patients  to  assist  the  progress  of  labor  by  voluntary  efforts.  Anesthesia 
to  the  surgical  degree  while  the  head  is  passing  the  vaginal  outlet  is  often  of 
the  greatest  value  in  preventing  perineal  laceration,  especially  in  primiparae. 
In  ordinary  cases  the  anesthesia  is  to  be  used  only  during  the  pains,  and  in 
quantities  only  sufficient  to  dull  the  pains,  complete  anesthesia  being  carefully 
avoided.  Anesthesia  after  delivery  should  be  dispensed  with  unless  impera- 
tively indicated.  Contraindications :  The  contraindications  to  the  use  of  anes- 
thesia during  labor  are  the  same  as  in  general  surgery,  with  the  important 
modification,  however,  that  the  excitement,  suffering,  and  muscular  exertion 
which  accompany  labor  without  anesthesia  may  be  more  dangerous  in  certain 
morbid  conditions — e.  g.,  cardiac  disease — than  the  anesthesia  itself.  Advan- 
tages: Anesthesia  during  labor  diminishes  pain;  in  certain  cases  aids  in  the 
progress  of  labor;  by  relaxing  the  tissues  aids  dilatation  of  the  cervix;  and  aids 

materially  in  the  preserva- 
tion of  the  perineum.     Dis- 
;  advantages:  In  some  cases 

it  diminishes  or  suspends 
uterine  contractions;  pro- 
duces unpleasant  or  dan- 
gerous after-effects ;  and 
predisposes  topost-partum 
hemorrhages;  and  if  exces- 
sively used,  to  subinvolu- 
tion and  consequent  sepsis. 
Administration  of 
Chloroform. — The  pa- 
tient being  in  the  recum- 
bent position  and  the  usual 
precautions  of  examining 
heart,,  lungs,  and  urine,  re- 
moving false  teeth,  and 
anointing  the  skin  about 
the  mouth  and  nose  having 
been  observed,  at  the  be- 
ginning of  a  pain  a  few 
drops  of  chloroform  are 
dropped  upon  a  towel  or 
napkin,  held  a  few  inches  from  the  nose  so  as  to  allow  a  sufficient  admix- 
ture of  air.  This  is  the  "drop"  method.  An  Esmarch  inhaler  is  convenient 
(Fig.  1040).  Valuable  rules  for  the  administration  of  chloroform  are:  (i)  Use 
as  little  chloroform  as  possible.  (2)  Use  napkin,  towel,  or  Esmarch  inhaler 
and  the  "drop  method."  (3)  Have  the  chloroform  vapor  well  diluted  with  air, 
especially  at  the  beginning  of  anesthesia.  (4)  At  first  use  only  during  uterine 
contractions.  (5)  When  an  operation  is  necessary,  disease  of  the  heart,  lungs, 
or  kidneys,  or  exhaustion  attendant  upon  the  third  stage,  are  not  contraindica- 
tions to  anesthesia.  Nevertheless  the  least  dangerous  anesthetic  or  combination, 
such  as  nitrous  oxide  and  ether  or  ether  and  oxygen,  should  be  employed,  and 
extreme  care  exercised  in  their  administration.  Valuable  danger-signals  in 
chloroform  narcosis  are:  (i)  Sudden  paleness  or  lividity  of  the  face.  (2)  Shal- 
low, sighing  respiration.  (3)  Rapid,  irregular,  intermittent,  or  failing  pulse. 
(4)  Sudden  dilatation  of  the  pupils. 


Fig.  1040.- 


-The  Administration  of  Chloroform  with 
AN  Esmarch  Inhaler. 


ANESTHESIA  IN  OBSTETRICS. 


867 


Administration  of  Ether. — If  ether  is  used,  the  quantity  may  be  somewhat 
larger,  and  an  improvised  cone,  made  from  a  newspaper  or  a  folded  towel,  may  be 
employed.  Both  in  normal  labor  and  obstetric  surgery  I  am  accustomed  to  use  an 
Allis  inhaler  (Fig.  1041)-  I  begin  its  use  in  the  latter  half  of  the  second  stage,  often 
earlier,  as  early  as  the  end  of  the  first  stage;  in  the  last  instance,  however,  only 
during  the  acme  of  the  pains,  and  to  a  very  moderate  degree  of  anesthesia. 

2.  For  Obstetric  Operations. — Choice  Between  Chloroform  and  Ether. — 
The  choice  of  an  anesthetic  for  obstetrical  operations  will  vary  with  the  operator. 
In  the  case  of  an  operation  performed  before  the  beginning  of  labor,  we  are 
influenced  in  our  choice  by  the  same  conditions  which  would  influence  us  in 
the  performance  of  any  surgical  operation.  The  only  exception  to  the  rule  is 
in  the  case  of  puerperal  eclampsia,  in  which  most  authorities  advise  the  use 
of  chloroform  in  preference  to  ether.  In  Europe  and  in  the  southern  and 
western  portions  of  this  country  chloroform  is  usually  preferred,  although  ether 
is  undoubtedly  gaining  ground,  while  in  the  northern  and  eastern  sections  of 
this  country  ether  is  used  in  the  great  majority  of  cases.  In  the  face  of  modem 
statistics  there  can  be  little  doubt  that  under  ordinary  circumstances,  and 
especially  in  the  hands  of  any  but  an  expert  anesthetist  of  large  experience, 
ether  is  the  safer,  and  therefore  the 

preferable  anesthetic.  Chloroform 
is  undoubtedly  the  more  convenient, 
but,  as  I  have  remarked  in  another 
connection,  no  question  of  conveni- 
ence should  be  allowed  to  interfere 
with  the  safety  of  the  patient.  The 
ordinary  alleged  contraindications  to 
the  use  of  ether,  such,  e.  g.,  as  pul- 
monary and  nephritic  complications, 
etc.,  are  discussed  in  text-books 
upon  surgery,  to  which  the  student 
is  referred. 

3.  Anesthesia  as  an  Aid  in  Diag- 
nosis.— In  doubtful  cases  it  is  some- 
times necessary  to  insert  the  hand 
into  the  uterus  in  order  to  make  a 

positive  diagnosis.  In  these  cases  one  should  carry  the  anesthesia  to  the 
surgical  degree,  since  complete  relaxation  greatly  facilitates  the  examination. 
The  anesthesia,  however,  should  be  discontinued  as  soon  as  practicable. 

Other  Anesthetics. — Chloral  is  a  valuable  agent  for  inducing  analgesia  during 
labor.  Under  its  influence  the  severity  of  the  pains  is  diminished  and  between 
the  pains  the  patient  is  drowsy  and  comfortable.  It  also  helps  materially  in 
aiding  dilatation  of  the  cervix.  It  is  especially  useful  in  the  case  of  nervous 
and  sensitive  women  and  in  cases  in  which  the  severity  of  the  pain  is  out  of 
proportion  to  the  progress  of  the  labor.  Chloral  may  be  given  in  fifteen- 
grain  doses  repeated  at  intervals  of  twenty  minutes.  Not  more  than  three 
doses  should  be  given,  and  one  or  two  are  usually  sufficient.  Morphin,  either 
by  the  mouth  or  hypodermic  ally,  is  sometimes  useful,  especially  when  anemia 
or  debility  renders  other  agents  inadvisable.  (See  Prolonged  Labor,  page  572.) 
Antipyrin  in  large  doses  has  been  successfully  employed,  but  in  the  presence 
of  safer  methods  its  use  does  not  seem  advisable.  The  topical  application 
of  a  solution  of  cocain  to  the  cervix  produces  a  limited  degree  of  anesthesia 
during  the   stage   of  dilatation.     The   objections   to  its  use  are  the  possibility 


Fig.  1041. — Self-administratiox  of  Ether 
WITH  AN  Allis  Inhaler  for  Dulling  the 
Intensity  of  the  Pains. 


868  OBSTETRIC  SURGERY. 

of  constitutional  symptoms,  and  the  danger  of  sepsis  from  intravaginal  manipu- 
lations. 

Spinal  Anesthesia. — Until  further  reliable  confirmation  of  the  safety  and 
value  of  lumbar  anesthesia  is  received,  it  seems  advisable  for  obstetricians  in 
general  to  refrain  from  exposing  their  patients  to  its  dangers. 

Conclusions. — (i)  For  operations  requiring  anesthesia  to  the  surgical  degree, 
ether,  unless  contraindicated,  is  to  be  preferred,  except  in  cases  of  eclampsia. 

(2)  In  surgical  anesthesia  during  labor  in  which  the  operation  is  begun 
under  chloroform,  and  especially  in  the  case  of  anemic  and  exhausted  patients, 
ether  may  advantageously  be  substituted  for  the  remainder  of  the  operation. 

(3)  For  dulling  the  pains  of  labor,  chloroform  carefully  used,  and  carried  only 
to  the  extent  of  primary  anesthesia,  is  both  convenient  and  relatively  safe;  but 
when  this  intermittent  anesthesia  is  long  continued,  it  is  likely  to  affect  the 
fetus  injuriously  and  is  dangerous  to  the  mother,  and  ether  is  to  be  preferred. 

(4)  Chloral  and  morphin,  especially  the  former,  are,  when  indicated,  of  great 
value.  (5)  The  production  of  local  anesthesia  by  topical  applications  to  the 
cervix  is  not  to  be  advised. 


IV.  POSTURE  IN  OBSTETRICS. 

A  study  of  the  posture  assumed  during  labor  by  the  women  of  barbarous 
and  semi-civilized  races  teaches  us  nothing  of  practical  importance.  Custom 
rather  than  instinct  appears  to  dictate  the  choice  of  these  obstetric  attitudes. 
The  women  of  contiguous  tribes  may  show  notable  differences  in  this  respect. 
Those  who  are  interested  in  the  subject  of  labor  among  primitive  people  may 
consult  the  special  works  of  Engelmann  and  Witkowsky.  Instinct  may  indicate 
the  best  position  for  the  woman  at  a  given  moment,  but  we  have  no  right  to 
assume  hastily  that  this  position  would  be  the  best  for  other  women  or  for 
the  sex  as  a  whole.  Some  of  the  poses  adopted  by  women  under  these  cir- 
cumstances appear  to  be  distinctly  contraindicated  at  the  time.  Does  a  woman 
ever  instinctively  assume  the  Walcher  position  when  the  head  is  trying  to  enter 
the  brim?  However,  the  postures  assumed  by  the  vast  majority  of  women  in 
the  different  stages  of  labor  are  such  as  harmonize  with  the  mechanism  of 
labor;  thus,  when  the  fetal  head  is  high  the  patient  prefers  to  stand  erect, 
sometimes  even  leaning  a  little  backward.  After  the  head  has  passed  the  brim 
she  leans  forward,  or  perhaps  kneels  to  assume  the  sitting  position;  while  if 
lying  down,  she  draws  up  her  knees  and  perhaps  raises  the  head  and  shoulders. 
A  rational  study  of  the  relation  of  posture  to  labor  is  of  the  greatest  importance 
and  leads  to  most  practical  results. 

There  are  but  two  classes  of  posture  which  have  a  special  bearing  upon 
midwifery.  First,  those  which  alter  the  shape  of  the  pelvis;  second,  those  in 
which  the  pelvis  is  elevated  so  that  it  becomes  the  highest  portion  of  the  trunk. 
A  knowledge  of  the  former  enables  the  obstetrician  to  facilitate  delivery  through 
the  resulting  diminution  of  the  osseous  resistance;  while  familiarity  with  the 
latter  enables  him  to  retard  labor  and  replace  small  prolapsed  parts,  perform 
version,  etc.     These  classes  will  be  considered  in  detail. 

I.  POSTURES  WHICH  ALTER  THE  SHAPE  OF  THE  PELVIS. 

Owing  to  the  mobility  of  the  pelvic  articulations,  certain  changes  in  the 
position  of  the  patient  are  accompanied  by  corresponding  changes  in  the  dimen- 


POSTURE  IN   OBSTETRICS 


869 


sions  of  the  pelvis.  Owing  to  serous  infiltration  and  consequent  softening  of 
the  pubic  ligaments,  the  separation  of  the  bones  at  the  pubic  symphysis  is 
normally  exaggerated  during  pregnancy,  and  thus  the  circumference  of  the 
pelvic  inlet  somewhat  increased.  It  is  not  generally  recognized,  however,  that 
the  limited  but  appreciable  movements  of  which  the  sacro-iliac  joints  are  capable 
are  an  important  factor  in  the  production  of  changes  in  the  pelvic  dimensions. 
In  the  erect  position  or  in  the  horizontal  position  with  extended  thighs  there 
is  a  slight  backward  movement  of  the  sacrum  which  tends  to  increase  the  antero- 
posterior diameter  of  the  inlet.     On  the  contrary,  if  the  thighs  are  strongly 


Fig. 


1042.- 


-Erect  Posture,  showing  the  Parturient  Tract  and  Degree  of  Pelvic 
Inclination. 


flexed  and  the  body  is  bent  forward  the  upper  end  of  the  sacrum  is  tilted  forward 
and  its  lower  end  backward,  the  antero-posterior  diameter  at  the  inlet  being  thus 
diminished  while  that  of  the  outlet  is  increased.  As  a  result  of  the  study  of  the 
foregoing  facts,  and  by  imitating  the  methods  of  nature,  the  obstetrician  is  able  to 
produce  at  will  an  increase  of  the  conjugate  diameters  of  either  the  inlet  or  the 
outlet  of  the  pelvis.  The  fact  is  utilized  in  normal  labor,  as  I  have  already  noted. 
It  is  also,  as  we  shall  presently  see,  of  great  value  in  the  conduct  of  operative 
deliveries.  The  pelvic  inclination  varies  according  to  the  position  of  the  woman, 
and  may,  of  course,  be  abnormal  in  cases  of  pelvic  deformity.  This  variation  is 
dependent  upon  the  motion  which  exists  at  the  sacro-iliac  joints,  the  pelvic  brim 
swinging  a  little  upward  and  downward  according  to  the  position  of  the  patient. 


870 


OBSTETRIC  SURGERY. 


Separation  of  the  knees,  by  increasing  the  tension  of  the  iho-femoral  hgaments, 
increases  the  angle  of  inchnation.  The  normal  pelvic  inclination  in  the  standing 
position  is  from  50  to  60  degrees  (Fig.  1042).  The  pelvic  inclination  in  the  dorsal 
position  with  the  legs  extended  is  30  degrees  (Fig.  1043);  in  the  dorsal  position 
with  the  thighs  and  legs  flexed  and  heels  close  to  the  buttocks  with  knees  moder- 
ately separated  it  is  40  degrees  (Fig.  1045);  while  in  the  dorsal  position  with 
the  thighs  strongly  flexed  upon  the  abdomen  and  the  knees  widely  separated, 
namety,  the  exaggerated  lithotomy  position,  the  angle  is  60  degrees  (Fig.  1047). 

I.  The  Walcher  Posture  (Fig.  1046). — This  is  the  opposite  of  the  exaggerated 
lithotomy  position.  The  patient  is  placed  on  her  back  in  the  "cross-bed" 
position,  or  preferably  on  a  table,  in  such  a  manner  that  the  sacrum  rests  upon 
the  edge  of  the  table,  the  thighs  and  legs  being  allowed  to  hang  downward 
by  their  own  weight.  In  this  position  the  pelvic  inclination  is  increased  and 
the  Conjugate  diameter  of  the  pelvic  inlet  slightly  increased.     The  vaginal  outlet 


Fig.  1043. — Dorsal  Posture  with  Extended  Thighs,  showing  the  Parturient  Tract 
AND  THE  Degree  of  Pelvic  Inclination. — (From  a  photograph  taken  at  the  Emer- 
gency Hospital.) 


is  drawn  so  far  down  that  the  angle  formed  by  the  long  axis  of  the  uterus  with 
that  of  the  vagina  is  diminished,  and  the  utero-vaginal  canal  becomes  less 
curved  and  approaches  a  straight  line  (Fig.  1046).  Manual  manipulations  are 
thus  much  facilitated.  According  to  Walcher,*  the  conjugate  is  increased  from 
0.33  to  0.5  inch  (8.5  to  13  mm.).  Fothergill  estimates  the  average  difference 
between  the  conjugate  in  the  lithotomy  position  and  the  same  measurement 
in  the  Walcher  position  as  0.36  inch  (9.3  mm.).  At  the  New  York  Maternity, 
in  1898,  I  measured  several  series  of  cases  from  among  the  waiting  women 
with  a  Farabeuf  pelvimeter  (Fig.  214)  in  the  lithotomy  position  with  moderate 
flexion  of  the  thighs,  and  then  in  the  hanging  Walcher  posture.  A  gain  in  the 
true  conjugate  with  the  latter  position  was  readily  demonstrated.  This  increase 
in  the  true  conjugate  varied  from  one-fourth  to  one-half  an  inch  (0.635  cm.  to  1.27 
cm.),  averaging  higher  in  multigravidae  than  in  primigravidae.     The  mechanism  of 

*  "Ctbl.  f.  Gyn.,"  18S9,  S.  S92. 


POSTURE  IN   OBSTETRICS.  871 

the  Walcher  position  is  dependent  upon  the  motion  of  the  sacro-iliac  synchron- 
drosis,  and  is  explained  as  follows :  The  weight  of  the  limbs  hanging  from  the  edge 
of  the  table  causes  the  ilia  to  rotate  forward  and  downward  around  the  trans- 
verse axis  of  the  joint.  Thus  the  angle  made  by  the  plane  of  the  brim  with  the 
horizon  is  increased,  and  consequently  the  symphysis  pubis  is  brought  a  little 
forward  and  downward  and  a  little  further  from  the  sacrum.  (See  Fig.  1046.) 
It  should  not  be  forgotten  that  the  Walcher  position  may  be  utilized  in  breech 
presentations  as  well  as  in  vertex.* 

2.  Exaggerated  Lithotomy  Posture  (Fig.  1047). — Dorsal  postures  are  subdi- 
vided in  accordance  with  the  position  of  the  legs.  If  the  latter  are  horizontal, 
the  angle  of  the  inlet  is  30  degrees  (Fig.  1043).  If  the  thighs  and  legs  are  flexed, 
the  feet  resting  on  the  table,  the  angle  increases  to  40  degrees  (Fig.  1045);  and 
if  the  degree  of  flexion  is  extreme,  the  patient  being  in  the  exaggerated  lithotomy 


Fig.  1044. — Dorsal  Posture  with  Elevation  of  the  Thorax,  showing  the  Par- 
turient Tract  and  the  Degree  of  Pelvic  Inclination. — {From  a  photograph 
taken  at  the  Emergency  Hospital.) 

posture,  the  angle  is  60  degrees  (Figs.  1047,  1048).  With  increase  in  the  size 
of  the  angle  of  inclination,  the  fundus  tilts  backward  more  and  more,  while  the 
lower  portion  of  the  birth  canal  is  correspondingly  elevated.  The  angle  of  the 
two  portions  of  the  birth  tract,  uterine  and  vaginal,  appears  to  undergo  but 
little  change  during  flexion  of  the  limbs.  The  dorsal  position  with  extreme 
flexion  of  the  limbs  is  indicated  for  slight  degrees  of  obstruction  at  the  pelvic 
outlet  and  for  all  operations  after  the  head  has  passed  the  brim. 


2.  POSTURES  WHICH  ELEVATE  THE  PELVIS. 

These  are  four,  in  two  of  which  the  woman  is  prone,  knee-chest  and  exag- 
gerated lateral  prone,  in  the  others,  supine,  Trendelenburg  and  Trendelenburg- 

*  The  Walcher  position  was  described  and  illustrated  in  Italy  many  years  ago.  Its 
use,  however,  was  purely  empirical.  It  was  supposed  to  make  the  child  more  movable 
and  to  be  useful  in  the  delivery  of  fat  patients.  It  remained  for  Walcher  to  demonstrate 
the  mechanism  involved  and  thus  to  place  the  matter  upon  a  scientific  basis. 


872 


OBSTETRIC  SURGERY. 


Walcher.  The  general  result  of  these  high  pelvic  positions  is  naturally  one  of 
gravitation.  The  pelvic  viscera  sink  toward  the  diaphragm,  and  the  result  from 
the  obstetrical  standpoint  is  twofold.  First,  the  fetus  sinks  away  from  the  cer- 
vix, with  the  result  in  the  first  stage  that  the  uterine  contractions  are  diminished 
in  force  and  frequency.  The  second  consequence  of  the  high  pelvic  postures 
is  that  the  pelvis  becomes  more  ample,  so  that  the  entire  hand  may  readily  be 
introduced.  The  combined  results  of  elevation  of  the  pelvis  give  the  obstetrician 
a  high  degree  of  control  over  certain  phenomena  of  normal  and  pathological 
labor.  He  can  delay  rupture  of  the  bag  of  waters,  antagonize  over-strong 
pains,  facilitate  certain  manoeuvers  which  are  best  done  with  the  entire  hand 
in  the  vagina,  and  prevent  the  redescent  of  the  small  parts  of  the  fetus. 

I,  Knee-chest  Posture  (Fig.  1049). — Sims,*  in  his  original  description  of  this 
position,  states  that  the  woman  should  first  kneel  and  then  bend  the  body 


Fig.  1045. — Dorsal  Posture  with  Moderate  Flexion  of  the  Thighs,  showing  thb 
Parturient  Tract  and  the  Degree  of  Pelvic  Inclination.  Note  the  slight  up- 
ward rotation  of  the  symphysis  and  enlargement  of  the  pelvic  outlet. — (From  a  pho- 
tograph taken  at  the  Emergency  Hospital.) 


forward  till  the  head  reaches  the  level  of  the  table,  where  it  should  rest  upon 
the  two  hands.  The  weight  is  supported  by  the  left  parietal  bone,  the  elbows 
being  thrown  out  widely  at  the  sides.  The  knees  should  be  8  or  10  inches 
(20.32  or  25.4  cm.)  apart  and  the  thighs  should  form  nearly  a  right  angle  with 
the  table.  The  woman  thus  supported  should  remain  perfectly  quiet,  only  the 
necessary  muscles  being  contracted.  After  a  few  moments'  interval  the  abdomi- 
nal and  pelvic  viscera  gravitate  toward  the  epigastrium.  It  is  apparent  that 
in  the  knee-elbow  position  the  weight  in  front  is  supported  upon  the  forearms, 
while  a  knee-chest  position  is  impossible  unless  pillows  are  placed  beneath 
the  chest. 

2.  Latero-prone  Position  with  Elevated  Hips  (Figs.  1050  and  1051). — This  is 
perhaps   superior,   in   filling  certain   indications,   to   both   the   knee-chest   and 
*  "Clinical  Notes  on  Uterine  Surgery." 


POSTURE  IN   OBSTETRICS. 


873 


Trendelenburg  positions.  It  is  far  more  acceptable  to  the  patient,  who  can 
assume  it  for  an  indefinite  period.  She  may  lie  at  first  in  the  ordinary  lateral 
decubitus  and  then  have  one  side  of  the  pelvis  gradually  elevated  by  slipping 
cushions  under  the  hip.  Other  cushions  are  placed  beneath  the  head  and 
chest,  as  these  structures  support  the  weight  in  front.  The  woman  rests  upon 
the  side  of  the  head,  the  entire  breast,  and  the  side  of  one  knee.  The  elevation 
of  the  buttocks  appears  to  equal,  for  all  practical  purposes,  that  produced  by 
the  Trendelenburg  and  knee-chest  positions.  Obstetricians  of  a  bygone  age 
(Deventer,  Ritgen)  counsel  the  employment  of  this  attitude,  although  they 
seem  to  regard  it  as  a  makeshift  for  the  more  efficacious  but  hardly  en- 
durable   knee-chest    posture.     It    is  probable    that  they  did    not  attempt  to 


jts^_ 


M. 


"•'■  -•"^'■•■'"■^'iifiTrtT^r-lfTiif' 


Fig.  1046. — Walcher  Posture,  showing  the  Parturient  Tract  and  the  Degree 
OF  Pelvic  Inclination.  Note  the  downward  rotation  of  the  symphysis  and  the 
enlargement  of  the  pelvic  inlet. — (From  a  photograph  taken  at  the  Emergency  Hospital.) 


elevate  the  pelvis  beyond  a  certain  limited  height.  The  superiority  of  the 
exaggerated  latero-prone  position  lies  in  its  adaptability  and  modesty  as  com- 
pared w^th  the  knee-chest  position.  For  many  years  I  have  used  it  in  my 
practice  to  the  exclusion  of  the  uncomfortable  knee-chest  posture. 

hidications  for  the  Knee-chest  and  Exaggerated  Lateral  Prone  Postures. — These 
two  postures  are  of  service  during  pregnancy,  labor,  and  the  puerperium.  In 
pregnancy  they  are  useful  for  external  ballottement  and  also  for  exploring  the 
sides  of  the  pelvis.  Generally  speaking,  examinations  in  these  positions  give 
results  which  supplement  those  obtained  by  exploration  in  the  dorsal  attitude. 
From  a  therapeutic  standpoint  the  postures  are  of  some  use  in  procuring  tem- 
porary relief  from  all  conditions  which  arise  from  pressure  of  the  gravid  uterus 
on  the  tissues  beneath  (hemorrhoids,  constipation,  vesical  trouble,  obstruction 


874 


OBSTETRIC  SURGERY. 


of  ureters,  etc.).  Late  in  pregnancy  the  woman  may  systematically  assume 
these  positions  at  stated  intervals.  Early  in  the  course  of  gestation  it  is  sorae- 
times  possible  to  relieve  the  vomiting  of  pregnancy  by  this  means.  For  one 
complication  of  pregnancy,  retrodisplacement  of  the  uterus,  this  postural  treat- 
ment is  indispensable,  although  manual  reposition  is  used  as  an  accessory 
measure.  (Seepage  278.)  In  labor  the  assumption  of  the  knee-chest  or  lateral 
prone  position  arrests  contractions  for  the  time  being.  In  normal  labor  there 
is  no  very  strong  indication  for  the  assumption  of  these  positions.  They  directly 
antagonize  the  action  of  gravity  in  promoting  labor,  and  are  thus  distinctly 
contraindicated  in  the  first  stage.  In  theory  they  might  be  indicated  when 
precipitate  labor  is  threatened,  and  in  attempts  to  defer  rupture  of  the  bag 
of  waters.     There  is  no  indication  for  forceps  delivery  in  these  postures,  but 


Fig.  1047. — Dorsal  Posture  with  Extreme  Flexion  of  the  Thighs,  showing  the 
Parturient  Tract  and  the  Degree  of  Pelvic  Inclination.  Exaggerated 
Lithotomy  Position.  Note  the  extreme  upward  rotation  of  the  symphysis  and  the 
enlargement  of  the  pelvic  outlet,  and  diminution  of  the  pelvic  inlet. —  (From  a  photo- 
graph taken  at  the  Emergency  Hospital.) 


in  version  they  present  numerous  advantages:  (i)  The  uterus  sags  away  from 
the  pelvis,  giving  the  operator  more  room  to  introduce  his  hand;  (2)  labor  pains 
are  arrested  for  the  time  being,  and  (3)  there  is  a  natural  tendency  on  the  part 
of  the  knee-chest  position  to  favor  the  rectification  of  the  malposition  for  which 
version  is  required.  These  postures  are  most  valuable  in  connection  with  pro- 
lapse of  the  funis,  yet  in  this  manual  replacement  must  generally  be  employed 
as  an  adjunct.  In  1882  Galbraith  brought  about  the  unlocking  of  twins  by 
causing  the  mother  to  assume  the  knee-chest  posture.  In  theory,  at  least,  the 
latter  should  favor  the  reposition  of  an  inverted  uterus. 

Of  the  hanging  dorsal  or  Trendelenburg,  and  the  arched  dorsal  or  Trendelen- 
burg-Walcher  positions,  the  latter  is  but  little  known,  having  been  but  recently 
revived  from  mediaeval  obscurity  by  Dr.  R.  L.  Dickinson.  The  pelvic  elevation 
is  very  slight  in  the  latter,  and  it  might  perhaps  be  better  described  as  a  hybrid 


POSTURE  IN   OBSTETRICS.  875 

posture  in  which  the  size  and  height  of  the  pelvis  are  simultaneously  affected. 
Each  position  is  described  in  detail. 

3.  Trendelenburg  Posture  (Fig.  1052). — While  this  posture  appears  to  be  a 
lineal  descendant  of  an  old  method  of  applying  taxis  in  hernia,  its  use  has  become 
general  only  of  late  years,  so  that  the  knee-chest  position  is  very  much  its 
senior  in  obstetric  practice.  A  woman  in  the  Trendelenburg  position  lies  upon 
her  back  with  her  head  and  arms  fiat  upon  the  operating  table  while  the  rest 
of  her  person  is  elevated  to  an  angle  of  45  degrees  or  less,  except  the  legs,  which 
hang  over  the  foot  of  an  inclined  plane.  The  weight  of  the  body  is  supported 
by  the  head  and  knees  (Fig.  1052).  If  the  angle  of  elevation  attains  a  certain 
size,  it  is  necessary  to  strap  the  legs.  This  posture  may  be  improvised  in  various 
ways:  thus,  an  incline  may  be  formed  from  an  inverted  chair  and  several  pillows, 


7- 


Fig.   1048. — Exaggerated  Lithotomy  Posture. 


or  the  woman  may  rest,  head  down,  upon  the  back  of  a  strong  attendant  with  her 
knee  hollows  upon  his  shoulders  and  her  legs  held  in  his  hands.  This  was  the 
earliest  application  of  the  method.  The  Trendelenburg  position  is  used  extensively 
in  the  laparotomies  incidental  to  obstetrical  practice,  as  in  ectopic  pregnancy. 
Aside  from  this,  it  has  been  proposed  as  a  substitute  in  certain  cases  for  the  knee- 
chest  position.  Its  advantages  over  the  latter  are  that  it  is  more  natural  and 
modest,  andean  be  endured  indefinitely,  thereby  antagonizing  a  further  tendency 
to  prolapse  of  the  small  parts.  It  does  not  conflict  with  the  administration  of 
anesthesia. 

4.  Walcher-Trendelenburg  Posture  (Fig.  1053). — In  the  Walcher  position  as 
usually  assumed,  the  direction  of  the  axis  of  the  utero- vaginal  canal  is  almost 
perpendicular,  and  traction  with  the  hand  or  forceps  must  be  directly  down- 
ward.    For  this  reason  a  combination  of  the  Walcher  position  with  the  well- 


876 


OBSTETRIC  SURGERY 


known  Trendelenburg  is  advised.*  In  this  way  the  advantages  of  the  former 
position  are  realized  while  the  vulva  is  at  such  a  height  that  traction  can  con- 
veniently be  made.  The  axis  of  the  utero-vaginal  canal  is  horizontal  and 
manipulations  are  thus  facilitated.  A  satisfactory  table  for  this  position  may 
be  improvised  by  means  of  an  ordinary  inverted  chair  and  a  mattress. 

Conclusions. — From  the  foregoing  the  following  conclusions  may  be  deduced: 
(i)  When  the  head  is  arrested  at  the  pelvic  brim,  either  the  Walcher  or  the 
Walcher-Trendelenburg  position  is  worthy  of  trial.  (2)  For  all  operative  cases 
in  which  the  greatest  circumference  of  the  head  has  passed  the  brim,  the  ex- 
aggerated lithotomy  position  is  to  be  preferred. 


Fig. 


1049. — Knee-chest  Posture,  showing  the  Parturient  Tract  and  the  Degree 
OF  Pelvic  Inclination. — (From  a  photograph  taken  at  the  Emergency  Hospital.) 


Posture  as  an  Aid  to  Childbirth. — In  retroversion  of  the  pregnant  uterus  the 
patient  should  be  placed  in  the  knee-elbow  or  the  exaggerated  latero-prone  posi- 
tion, in  order  that  reposition  of  the  uterus  may  be  attempted.  In  over-strong  pains, 
to  prevent  precipitate  labor  the  patient  should  be  placed  upon  her  side  and  for- 
bidden to  bear  down.  In  labor  in  contracted  pelvis,  with  slight  disproportion  be- 
tween the  head  and  inlet,  Walcher's  position  should  be  assumed  during  engage- 
ment in  the  inlet.  If  a  similar  degree  of  contraction  exists  at  the  outlet,  the 
exaggerated  lithotomy  position  should  be  assumed.  In  the  ftrst  stage  of  labor  pos- 
ture is  generally  left  to  the  decision  of  the  parturient.  She  may  be  seated  or  may 
*  Dickinson:   "American  Journal  of  Obstetrics,"  Dec,  1898,  p.  791 


POSTURE  IN  OBSTETRICS. 


877 


walk  about.  An  upright  position  is  held  to  be  of  advantage  because  the  weight 
of  the  fetus  may  stimulate  the  cervix  to  dilate.  However,  when  dilatation  is 
nearly  complete  there  is  some  danger  of  precipitate  expulsion,  with  possible 


Fig.  1050. — Exaggerated  Lateral  Prone  Posture.     Anterior  View. — (From  a  photo- 
graph taken  at  the  Emergency  Hospital.) 

rupture  of  the  cord  or  injury  to  the  child.  It  has  been  suggested  as  a  com- 
promise that  the  woman  should  squat  or  kneel  during  the  latter  part  of  the 
first  stage,  for  she  thereby  retains  the  benefit  of  the  upright  position  without 
the  risks  just  enumerated.     In  the  second  stage  of  labor  the  natural  tendency 


^" 


^ 


-- ^H-^-^' 


Fig.     1051. — Exaggerated    Lateral    Prone    Posture.     Posterior    View.- 
photograph  taken  at  the  Emergency  Hospital.) 


-{From    a 


during  the  expulsion  period  is  toward  the  assumption  of  the  dorsal  position. 
It  has  been  ascertained  that  a  reclining  attitude  facilitates  the  first  half  of 
the  second  stage,  while  during  the  second  half  the  woman  should  turn  on  that 


878 


OBSTETRIC  SURGERY. 


side  toward  which  the  fetal  back  presents,  with  her  legs  strongly  flexed.  This 
position  is  believed  to  favor  perfect  flexion  of  the  child's  head.  It  is  used 
almost  universally  in  Great  Britain  throughout  the  second  stage.  While  conduc- 
ing to  modesty,  it  also  lessens  the  intensity  of  the  expulsive  forces  during  perineal 
dilatation  by  bringing  gravity  into  play.  In  the  third  stage  of  labor  the  woman 
should  lie  flat  on  her  back  with  the  head  low.  In  occipito-posterior  positions 
before  labor  has  set  in,  the  woman  should  assume  the  knee-chest  or  latero-prone 
position  with  elevated  hips  in  the  hope  that  the  head  will  engage  in  the  natural 
way  After  labor  is  under  way  she  should  assume  the  latero-prone  position 
on  the  side  toward  which  the  fetal  back  is  directed.  In  mento-posterior  positions 
the  patient  should  be  placed  on  the  same  side  as  that  toward  which  the  fetal  ab- 
domen is  turned.  This  posture  favors  the  desired  extension  and  anterior  rotation 
of  the  chin.     With  prolapse  of  an  arm,  after  the  head  has  been  pushed  up,  the 


Fig.   1052. — Trendelenburg  Posture,  showing  the  Parturient  Tract  and  the  De- 
gree OF  Pelvic  Inclination. — {Froin  a  photograph  taken  at  the  Emergency  Hospital.) 


uterine  obliquity  usually  present  is  corrected  by  having  the  patient  lie  on  the  side 
opposite  to  that  to  which  the  fundus  inclines.  The  head  should  now  be  able  to 
engage  without  the  arm.  With  presentation  and  prolapse  of  the  cord  our  resource 
is  often  posture.  The  patient  should  be  placed  in  the  knee-elbow  or  exaggerated 
semi-prone  posture  for  ten  minutes.  The  head  then  falls  away  from  the  os  and 
sinks  into  the  cavity  of  the  uterus.  Actual  prolapse  of  the  cord  requires  the  same 
postural  treatment.  With  short  cord  the  mother  may  assume  a  squatting  or  kneel- 
ing posture  (page  559).*  In  heart  failure  an  asystolic  woman  can  often  be  safely 
delivered  in  a  reclining  attitude  with  the  thorax  raised  and  afterward  may  regain 
some  compensation  (Fig.  1044).  It  is  held  that  this  position  aids  the  failing 
heart  and  respiration  by  removing  some  of  the  pressure  from  the  diaphragm. 
In  post-partum  hemorrhage  the  patient  should  be  flat  on  her  back  without  pillows 
and  the  foot  of  the  bed  elevated.  This  posture  is  indicated  also  in  ante-partum 
*  Brickner:   "Am.  Jotir.  Med.  Sciences,"  Nov.,  1899. 


VAGINAL  EXAMINATION. 


879 


and  intra-partum  hemorrhages.  In  forceps  delivery  the  patient  is  usually  placed 
in  the  lithotomy  position.  In  England  she  lies  in  the  ordinary  obstetrical 
position,  upon  the  left  side.  The  English  and  American  methods  can  be  com- 
bined by  applying  the  blades  in  the  former  and  extracting  in  the  latter  position. 
In  very  difficult  extraction  the  Walcher  position  may  be  employed  until  the 
head  has  passed  the  inlet,  after  which  the  lithotomy  position  is  assumed.  In 
version  the  woman  is  placed  in  the  Trendelenburg,  Walcher,  Trendelenburg- 
Walcher  or  exaggerated  lithotomy  position  according  to  the  stages  and  difficulties 
of  the  operation.  In  dorso-posterior  positions  one  may  employ  the  latero-prone 
position,  the  woman  lying  on  the  side  at  which  is  the  fetal  pole  which  is  to  be 
brought  down.     In  case  the  presenting  part  is  firmly  engaged  in  the  inlet,  the 


\ 


^A^*"'' 


Fig.  1053. — -Trendelenburg-Walcher  Posture,  showing  the  Parturient  Tract  and 
THE  Degree  of  Pelvic  Inclination.  Note  the  downward  rotation  of  the  sym- 
physis and  the  enlargement  of  the  pelvic  inlet. — {From  a  photograph  taken  at  the  Emer- 
gency Hospital.) 

knee-elbow  position  may  be  used,  although  I  have  found  the  exaggerated  latero- 
prone  or  Trendelenburg  posture  to  answer  better.  In  the  puerperium,  for  the 
first  two  or  three  days  the  dorsal  posture  is  advisable  (page  694).  After  the 
third  day  the  patient's  time  should  be  equally  divided  between  the  dorsal,  two 
lateral,  and  if  possible  the  abdominal  posture  (fiat  on  belly)  (page  694).  Drain- 
age is  promoted  by  an  early  propping  up  of  the  shoulders. 


V.  VAGINAL  EXAMINATION. 


See  Asepsis  in  Obstetrics,  page  14S. 


880 


OBSTETRIC  SURGERY. 


VI.  DIGITAL  EXPLORATION  OF  THE  UTERUS. 

This  procedure  is  often  necessary  in  the  diagnosis  of  incomplete  abortion 
and  septic  conditions,  and  is  performed  as  follows:  The  patient  is  placed  in  the 
lithotomy  position,  the  operator's  hands  and  arms  and  the  vulva  are  carefully 
disinfected,  and  the  vagina  is  irrigated.  Two  fingers  of  the  right  hand  are  then 
introduced  into  the  vagina  and  passed  through  the  cervix,  the  left  hand  mean- 
while being  placed  upon  the  fundus  and  the  uterus  being  pressed  downward 
and  backward  into  the  axis  of  the  bony  pelvis  (Fig.  1054).     In  this  way  the 


Fig.  1054. — Digital  Exploration  of  the  Uterus, 


uterus  may  be  pressed  over  the  examining  fingers  like  a  glove.  The  anterior, 
posterior,  and  lateral  walls  of  the  uterus  are  then  to  be  systematically  palpated 
especial  attention  being  paid  to  the  comua,  where  retained  decidua,  chorion, 
or  placenta  is  apt  to  escape  notice  (Fig.  1054).  The  condition  of  the  uterine 
walls  is  thus  appreciated  and  the  presence  or  absence  of  placenta  or  membranes 
noted.  In  some  cases  it  may  be  necessary  to  introduce  the  entire  hand  into 
the  uterus.  This  can  be  done  only  when  the  patient  has  been  recently  delivered 
and  the  cavity  is  of  sufficient  size.  If  the  patient  is  unusually  nervous  or  sensi- 
tive, primary  anesthesia  will  first  be  necessary. 


VULVAL  DOUCHE— VAGINAL  IRRIGATION. 


881 


VII.  VULVAL  DOUCHE. 

It  is  often  important  that  the  vulva  should  be  flushed  out  thoroughly  in 
its  inner  aspect  and  not  merely  washed  on  the  outside,  as  is  the  ordinary  custom. 
The    inside    of   the    vulva,    in    marked 
contrast  with  the  vagina,  is  the  habitat 
of    many  germs,   and    in    certain    cases 

infection  may  be  due  to  micro-organisms  -(^^i^ 

from  the  vulva  carried  into  the  birth 
tract  on  the  exploring  finger.  The  vulval 
douche  is  therefore  intended  to  cleanse 
the  inner  aspect  of  the  external  genitals. 
The  woman  should  lie  on  her  back  upon 
a  douche  pan  or  a  Kelly  pad  with  limbs 
somewhat  abducted  (Fig.  1048).  The 
labia  majora  are  held  wide  apart  by  the 
fingers  (Fig.  1055),  while  by  the  aid 
of  an  ordinary  irrigation  apparatus  a 
stream  of  water  is  directed  through  a 
glass  nozzle  upon  the  labia  minora, 
clitoris,  vestibule,  and  other  parts  com- 
prising the  vulva.  The  cleansing  can 
also  be  accomplished  after  wide  open- 
ing of  the  vulva  with  pledgets  of 
absorbent  cotton  first  dipped  in  a 
soap  solution,  then  in  sterile  water,  and 
lysol  or  sublimate  solution.  To  avoid 
should  always  be  from  above  downward. 


Fig.   1055. — The  Vulval  Douche. 

finally  in  an  antiseptic,  such  as   a 
rectal    contamination,    the   sponging 


Vlll.  VAGINAL   IRRIGATION. 

In  this,  as  in  all  other  obstetric  procedures,  every  care  should  be  taken  to 
prevent  the  introduction  of  infection.  The  vulva  and  adjacent  regions  and  the 
hands  of  the  physician  should  be  cleansed  as  before  a  vaginal  examination. 
(See  Asepsis  in  Obstetrics,  page  150.)  The  patient  should  be  in  the  dorsal 
position;  a  glass  or  metal  tube  which  can  be  sterilized  by  boiling  is  to  be  pre- 
ferred (Fig.  1057).  The  intrauterine  tube  may  be  used,  but  a  straight  tube 
is  less  likely  to  enter  the  cervix  or  to  carry  fluid  into  the  uterine  cavity.  In 
all  cases,  as  in  vaginal  and  uterine  manipulations,  the  vulval  canal  should  first 
be  obliterated  with  the  free  hand  before  the  introduction  of  the  irrigating 
tube  (Fig.  1056).  Special  attention  is  to  be  directed  to  the  posterior  cul-de-sac, 
where  there  is  apt  to  be  an  accumulation  of  stagnant  secretions.  Special  care 
is  to  be  taken  also  that  the  tube  does  not  enter  the  cervix  and  that  infectious 
secretions  are  not  washed  into  the  uterus.  If  necessary,  a  finger  in  the  vagina 
should  be  employed  to  make  sure  that  the  uterine  cavity  is  not  invaded.  A 
common  practice  in  recent  years  has  been  to  close  tightly  the  vaginal  outlet 
about  the  irrigating  tube,  in  order  to  increase  the  intravaginal  pressure,  balloon 
the  walls,  and  secure  a  more  thorough  cleansing.  This  in  the  presence  of  a 
puerperal  uterus  must  be  employed  with  caution,  and  never  without  a  firm 
grasp  of  the  fundus,  and  only  with  moderate  increase  of  intravaginal  pressure. 
56 


882 


OBSTETRIC  SURGERY. 


A  fountain  syringe  is  to  be  preferred  for  vaginal  as  for  intrauterine  injections. 
The  temperature  of  the  solution  should  be  from  105°  to  110°  F.     There  is  no 
advantage  in  a  high  degree  of  heat  unless  hemorrhage  exists.     The  resorptive 
power  of  the  vagina  soon  after  delivery- 
is  greater  than  has  generally   been  sup- 
posed.    Stronger  sublimate  solutions  than 
I   :  5000    should    not    be   used.     For    the 


W^h 


Fig.   1056. — The  Vaginal  Douche. 


Fig. 


1057- 


-Blunt  Vaginal  Douche 
Tube. 


various  solutions  to  be  used  in  vaginal  as  well  as  intrauterine  injections,  see 
Treatment  of  Puerperal  Infection  (page  726).  Valuable  ones  are,  i  :  5000 
sublimate;  2  per  cent,  carbolic  acid;  0.5  per  cent,  lysol  or  creolin;  decinormal 
saline  solution,  and  plain  sterile  water. 


IX.  INTRAUTERINE  IRRIGATION. 

j^An  intrauterine  injection  is  by  no  means  an  indifferent  procedure,  and 
should  be  regarded  as  an  operation — one  to  be  performed  with  scrupulous 
care  and  ^attention  to  detail.  The  following  are  the  sources  of  danger.  Shock 
from  uterine  distention  or  from  too  hot  or  too  cold  solutions;  poisoning,  e.  g., 
by  bichloride  of  mercury  or  carbolic  acid;  abrasions  of  the  soft  parts  resulting 
in    new   foci   of    infection;    dislodgment   of   clots   from    the  puerperal   venous 


INTRAUTERINE  IRRIGATION. 


883 


sinuses  which  may  enter  the  general  circulation,  and  entrance  of  fluid  into 
the  Fallopian  tubes  and  peritoneal  cavity. 

The  intrauterine  douche  tube  should  be  of  glass  or  metal,  that  it  may  be 
sterilized  by  boiling,  should  be  of  medium  caliber,  and  have  a  suitable  curve 
(Fig.  1059).  Tubes  of  tin,  the  shape  of  which  can  be  altered  at  will,  are  con- 
venient, and  metal  male  catheters  may  be  used  in  an  emergency.  The  tube 
should  be  perforated  at  the  sides  and  there  should  be  no  opening  at  the  end. 
The  current  of  fluid  should  be  continuous,  not  interrupted;  a  fountain  syringe 


Pig    105S. — Intrauterixe   Irrigation.     The  upper  illustration  shows  a  faulty  method. 

Note  the  firm  grasp  of  the  fundus. 


is  to  be  preferred,  and  every  care  should  be  taken  to  prevent  the  entrance 
of  air.  The  douche  bag  should  be  held  at  such  a  height  that  the  current  is 
sufficient  but  not  strong,  two  or  three  feet  above  the  patient's  pelvis  being 
usually  the  proper  height.  The  quantity  of  fluid  may  vary  with  the  indications, 
less  than  one  quart  being  rarely  used.  Solutions:  Within  the  uterus  we  irrigate 
with  plain  sterile  water  or  sterile  decinormal  saline  solution;  0.5  per  cent,  of 
creolin  or  lysol,  50  per  cent,  alcohol,  and  sublimate  solution  in  the  strength 
of  I  :  10,000,   which  last  should  be  followed  b}^  a  second  irrigation  of  plain 


884 


OBSTETRIC  SURGERY. 


sterile  water.  Administration:  The  patient  should  be  in  the  dorsal  position, 
and,  when  practicable,  in  the  lithotomy  position.  As  stated  elsewhere,  a 
recently  delivered  patient  should  never  be  placed  in  the  Sims  position  on 
account  of  the  danger  of  the  entrance  of  air  into  the 
uterine  sinuses.  It  is  rarely  necessary,  nor  is  it  advis- 
able, to  introduce  the  finger  into  the  vagina  as  a  guide 
to  the  cervix.  The  external  genitals  and  hand  having 
been  cleansed,  the  physician  sits  or  stands  at  the  side 
of  the  bed  or  in  front  of  the  patient,  and  with  the 
fingers  of  the  free  hand  obliterates  the  vulval  canal 
by  placing  the  outer  border  of  the  thumb  upon  the 
inner  aspect  of  one  labium  and  the  first  and  second 
fingers  upon  the  inner  surface  of  the  opposite  labium, 
and  widely  separates  them  (Fig.  1056).  The  irrigating 
tube  is  then  passed  directly  into  the  vagina  and  first 
a  thorough  vaginal  irrigation  is  administered,  during 
which  the  free  hand  firmly  grasps  the  fundus.  The 
fundus  is  then  pushed  backward,  and  by  the  sense  of 
touch  the  irrigating  tube  is  passed  on  into  the  uterus, 
always  remembering  to  keep  a  firm  grasp  upon  the 
fundus  to  prevent  dilatation  of  the  uterus  and  opening 
of  the  sinuses  (Fig.  1058). 

The  tube  should  be  carried  to  the  fundus,  and  care 
should  be  taken  that  the  soft  tissues  of  the  uterine  wall 
are  not  injured  by  rough  or  careless  movements.  Some 
instruments — e.  g.,  the  Fritsch-Bozeman  intrauterine 
catheter,  and  the  author's  irrigating  tube — provide  for 
the  return  of  the  fluid,  but  this  may  be  promoted,  if 
necessary,  whatever  instrument  is  used,  by  gentle  pres- 
sure with  the  instrument  against  the  anterior  lip  of  the 
cervix.  During  the  entire  process  the  patient  should 
be  carefully  observed,  and  at  the  first  evidence  of 
pallor  or  twitching  of  the  facial  muscles,  or  of  pain 
or  constitutional  disturbance,  the  injection  should  be 
stopped.  If  there  is  uterine  hemorrhage,  showing  the 
dislodgment  of  a  clot,  the  injection  should  be  suspended.  Retained  fluid  is 
best  expressed  by  compression  of  the  fundus. 


FRONT 
VIEW. 


CROSS  ^ 
SECTIONQD 


Fig.  1059.  —  Author's 
Return  Flow  Vag- 
i.NTAL  AND  Uterine 
Irrigating  Tubes. 


X.  THE  VAGINAL  TAMPON. 

This  is  best  applied  with  the  patient  in  the  Sims  position  and  the  perineum 
drawn  back  by  a  speculum.  The  dorsal  posture  and  a  perineal  retractor  can 
also  be  used.  The  external  genitals  should  be  disinfected  and  the  vagina  care- 
fully swabbed  out  with  a  piece  of  gauze  soaked  in  an  antiseptic  solution.  The 
tampon  should  preferably  be  of  gauze,  but  in  the  absence  of  this  material  may 
be  of  absorbent  cotton  or  lamp-wick,  soaked  in  an  antiseptic  solution.  The  use 
of  plain  sterile  gauze  is  not  advisable  owing  to  the  danger  of  decomposition 
of  retained  secretions.  In  order  to  be  efficient,  the  tamponing  should  be  done 
carefully  and  thoroughly.  It  requires  from  thirty  to  forty  yards  of  four-inch 
moist  gauze  to   properly  tampon  the  vagina  in  placenta  prsevia.     The  vaginal 


THK    UTERINE   TAMPON. 


885 


fomices  should  first  be  packed,  and  as  the  speculum  is  gradually  withdrawn  the 
rest  of  the  vagina  is  filled  (Fig.  1060).  The  tampon  is  held  in  position  by  a 
rather  tight-fitting  T-bandage  (Fig.  271).      It  should  not  remain  in  place  more 


Fig.   1060. — The  Vaginal  Tampon. 

than  twelve  hours.     At  the  end  of  this  time  it  should  be  removed,  and  a  second 
tampon  introduced  and  left  for  another  twelve  hours. 


XI.  THE  UTERINE  TAMPON. 

As  stated  elsewhere,  the  intrauterine  tampon  is  used  for  the  purpose  of 
controlling  hemorrhage  and  occasionally  in  the  treatment  of  septic  conditions. 
The  method  of  procedure  is  as  follows:  The  patient  being  in  the  lithotomy 
posture,  the  vulva  and  adjacent  regions  are  cleansed  and  the  vagina  is  irrigated; 
the  perineum  is  depressed  with  an  ordinary  retractor;  the  anterior  and  posterior 
cervical  Hps  are  seized  with  volsella  forceps  or  tenacula  and  the  uterus  is 
drawn  down  and  held  by  an  assistant  (Figs.  1061  and  1062).  A  long  strip  of 
gauze  is  now  passed  into  the  uterine  cavity  by  means  of  a  long,  blunt-pointed 
dressing  forceps.  The  strips  should  be  a  hand's-breadth  in  width  and  folded, 
and  about  three  or  four  yards  in  length,  for  the  full-term  puerperal  uterus,  and 
correspondingly  smaller  for  the  earlier  months.  Unmedicated  sterile  gauze  is 
to  be  preferred.  Every  precaution  should  be  taken  to  prevent  infection,  and 
the  gauze  should  be  carried  by  the  dressing  forceps  directly  from  its  special 
receptacle  into  the  uterus  without  touching  any  foreign  body  which  might  con- 
taminate it.  During  the  entire  operation  the  dressing  forceps  holding  the  gauze 
should  be    guided    and    controlled  by  the  external  hand  grasping  the  fundus. 


886 


OBSTETRIC  SURGERY. 


which  makes  sure  that  the  gauze  has  reached  the  fundus.     The  gauze  is  gradu- 
ally introduced,  the  object  being   completely  to    fill   the  uterine  cavity  from 
above    downward   (Figs.    1061    and    1062). 
A  loose  packing  is  left  in  the  vagina.      If, 
however,    in    cases     of    hemorrhage,    the 
bleeding    comes    from    the    lower    uterine 


Fig.   106 1. — Method    of  Packing   the  Puer- 
peral Uterus. — (From  a  photograph.) 


Fig.    1062. — Method    of    Packing  the 
Puerperal  Uterus. 


segment,  as  in  some  cases  of  placenta  praevia  or  cervical  laceration,  the  vaginal 

packing  should  be  tight. 

In  some  cases  the  uterus  may  be  pressed  down  so  far  that  it  is  not  necessary 

to  draw  it  down  by  means  of  in- 
struments, and  if  the  latter  are 
lacking,  the  gauze  may  usually 
be  introduced  by  means  of  the 
hand  being  passed  into  the 
uterine  cavity.  If  sterile  gauze 
is  not  at  hand,  clean  linen  or 
other  material  which  has  been 
boiled  and  soaked  in  a  disinfect- 
ant solution  may  be  substituted 
in  the  case  of  grave  emergency. 
A  most  convenient  method  for 
uterine  as  well  as  vaginal  tam- 
ponade will  be  found  in  the  use 
of  a  mechanical  surgical  dress- 
ing packer.*  I  have  for  several 
years  in  hospital  and  private 
YTj-  inch,  for  the  puerperal  uterus  of 


Fig. 


1063. — Packing    the    Puerperal 
with  a  Metal  Gauze-packer. 


Uterus 


work  used  two  sizes.  No.  3,  outside  diameter  ■^-^ 

*  Darmack  patent. 


ARTIFICIAL  RUPTURE  OF  MEMBRANES. 


887 


the  early  months,  and  for  packing  the  lower  uterine  segment  to  induce  abortion; 
and  No.  4,  outside  diameter  f  inch,  for  packing  the  larger  puerperal  uterus  and 
the  lower  segment  to  induce  premature  labor.  No.  3 
carries  gauze  from  ^  inch  to  i^V  inches  wide;  No.  4, 
from  4  inches  to  6  inches  (see  Figs.  1063  and  1069).  To 
use  the  instrument,  the  lithotomy  position,  with  the  peri- 
neum retracted  and  the  cervix  held  with  volsella  forceps,  is 
to  be  preferred. 

Hemorrhage  coming  on  in  from  half  an  hour  to  an  hour 
after  the  insertion  of  the  uterine  tampon  indicates  that  blood 
is  being  squeezed  from  the  gauze  by  uterine  contractions.  In 
such  a  case  further  tamponing  is  not  indicated,  but,  rather, 
the  removal  of  the  gauze.  The  tampon  should  not  be  allowed 
to  remain  in  situ  for  more  than  twelve  hours,  and  its  re- 
moval should  usually  be  followed  by  uterine  and  vaginal  irri- 
gation with  some  non-toxic  solution. 


XII.  PASSING  THE  CATHETER. 

The  patient  is  placed  in  the  dorsal  position  with  thighs 
rotated  outward.  The  labia  are  held  apart  by  the  fingers  of 
one  hand  (Fig.  1056),  while  with  a  pledget  of  cotton  dipped 
in  an  antiseptic  solution,  such  as  i  per  cent,  lysol,  the  vesti- 
bule is  carefully  wiped  from  above  downward.  A  glass  cath- 
eter (Fig.  1064),  previously  boiled,  is  then  introduced  into 
the  meatus  and  the  water  drawn.  Since  antisepsis  and  asepsis 
have  been  elaborated,  it  is  considered  wiser  to  catheterize  the 
woman  by  the  aid  of  direct  inspection  than  by  the  mere  sense 
of  touch.  For  special  directions  for  using  the  catheter,  see 
Affections  of  the  Bladder  in  Pregnancy  (page  318),  Labor  (page  478),  and  the 
Puerperium  (pages  706  to  708). 


Fir..  1064. — Gi,Ass 
Catheter. 


(B)  OPERATIONS  PPEPARATORY  TO  DELIVERY. 
I.  ARTIFICIAL  RUPTURE  OF  MEMBRANES. 

This  procedure  is  of  such  simplicity  that  it  hardly  deserves  to  be  ranked 
as  an  operation.  Indications :  When  the  cervix  is  fully  dilated  and  the  bag  of 
waters  is  gtill  intact,  the  obstetrician  may  interfere.  The  amniotic  fluid  has 
completely  discharged  its  function  of  aiding  the  first  stage  of  labor  and  would 
constitute  an  impediment  in  the  period  of  expulsion.  In  twin  labors  after  the 
birth  of  the  first  child,  the  os  being  well  open,  the  bag  of  waters  of  the  second 
twin  will  be  of  no  further  service,  and  should  be  ruptured  after  a  short  interval 
of  expectancy.  When  the  bag  of  waters  persists  throughout  labor,  the  mem- 
branes should  be  ruptured  immediately  lest  the  newly  born  child  be  asphyxiated. 
Artificial  opening  of  the  membranes  is  sometimes  indicated  with  the  os  not 
fully  dilated.     Thus  the  bag  of  waters  may  prolapse  through  a  partially  open  os, 


888 


OBSTETRIC  SURGERY. 


and  even  descend  to  the  level  of  the  vulva.  This  has  been  termed  the  "  sausage- 
shaped"  protrusion  of  the  bag  of  waters,  and  sometimes  stands  in  causal  relation 
to  premature  detachment  of  the  placenta.  On  this  account  alone  it  may  be 
necessary  to  rupture  the  membranes.  Again,  if  there  are  adhesions  between 
the  cervix  and  membranes  which  cannot  be  separated  by  the  finger,  artificial 
rupture  may  be  indicated.  In  placenta  praevia  lateralis  the  indication  is  for 
early  rupture  of  the  membranes  in  advance  of  dilatation,  in  order  that  the 

fetal  head  may  descend  and  compress  the  lower  seg- 
ment (page  223).  In  premature  detachment  of  a 
normally  seated  placenta  the  indication  is  the  same 
(page  228).  Finally,  most  cases  of  operative  inter- 
vention require  rupture  of  the  membranes.  Tech- 
nique :  The  fingers  should  pinch  up  a  fold  of  the 
membranes  and  tear  it  apart.  If  the  membranes  are 
very  firm  or  tense,  the  rupture  must  be  produced  by 
scissors  or  dressing  forceps,  or  any  sterile  pointed 
instrument. 


Fig.  1065.  —  Notched 
Thimble  for  Artifi- 
cial Rupture  of  the 
Membranes. 


II.  INDUCTION  OF  ABORTION  AND  PRE- 
MATURE LABOR. 

Definitions. — The  terms  abortion  and  premature 
labor  are  applied  with  considerable  looseness  by  var- 
ious writers  to  express  the  termination  of  pregnancy 
at  various  periods  before  term.  It  seems  logical,  how- 
ever, to  draw  the  line  at  the  approximate  period  of 
pregnancy  at  which  the  child  is  fitted  for  extrauterine 
existence,  i.  e.,  the  seventh  month,  and  to  divide  abor- 
tions into  early  and  late.  An  early  abortion  is  one 
occurring  within  the  first  twelve  weeks.  Up  to  this 
time  the  ovum  usually  comes  away  in  nearly  a  com- 
plete condition,  while  after  the  third  month  three  stages  of  labor  may  be  distin- 
guished. It  is  advisable  to  make  this  distinction  between  early  and  late  abortions, 
since  the  methods  of  treatment  for  each  period  are  different.  Induction  of  abor- 
tion is  performed  entirely  in  the  interest  of  the  mother;  induction  of  premature 
labor  may  be  done  in  the  interest  of  either  or  both. 

Importance. — For  the  conscientious  physician  the  interruption  of  pregnancy 
naturally  involves  great  responsibility,  but  when  it  is  the  only  method  of  saving 
the  lif^  of  the  mother,  or  when  without  it  her  life  is  placed  in  imminent  danger, 
it  is  usually  regarded  as  not  only  justifiable  but  imperative.  If  possible,  it 
should  always  be  preceded  by  a  consultation,  which  may  not  only  prevent 
the  unnecessary  sacrifice  of  fetal  life  but  protect  the  reputation  of  the  physi- 
cian. 

Indications  for  the  Induction  of  Abortion. — I  am  accustomed  to  make  two 
groups  of  these  indications,  namely,  (i)  General,  and  (2)  Local  Indications. 

I .  Chief  among  the  general  indications  is  the  toxemia  of  pregnancy,  which 
shows  itself  chiefly  in  the  early  months,  by  the  persistent  vomiting  of  pregnancy. 
Although  I  am  not  convinced  that  all  cases  of  persistent  vomiting  of  pregnancy 
have  an  autotoxic  origin,  still  I  believe  that  a  large  proportion  of  these  cases  are 
due  to  a  toxemia  peculiar  to  pregnancy,  possibly  of  hepatic  origin.     My  custom  is 


INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR.         889 


to  advise  immediate  induction  of  abortion  in  all  cases  showing  marked 
toxic  symptoms,  and  also  in  the  milder  type  after  stimulation  of  the 
functions  of  the  liver,  kidneys,  and  skin,  together  with  colonic  irriga- 
tions and  rectal  feeding  fail  to  mitigate  the  symptoms.  In  instances 
of  uncontrollable  vomiting  in  which  there  is  a  possible  neurotic  or 
reflex  cause,  and  in  which  decided  toxic  sympt6ms  are  absent,  one  is 
justified  in  using  an  expectant  treatment,  for  a  time,  but  never  after 
food  fails  to  be  retained,  emaciation  becomes  evident,  and  the  pulse 
very  rapid.  Under  these  latter  conditions  a  therapeutic  abortion  is 
not  only  justifiable  but  demanded,  as  too  many  lives  have  been  sacri- 
ficed in  the  past  by  procrastination. 

Renal  insufficiency  from  acute  and  chronic  nephritis  usually  asserts 
itself  toward  the  last  third  of  gestation,  hence  I  have  considered  this 
condition  under  the  induction  of  premature  labor.  The  same  indica- 
tions, however,  hold  good  in  the  first  two-thirds  of  pregnancy. 

Advanced  cardiac  and  pulmonary  disease  have  been  considered  on 
pages  325  and  331;  and  gestational  mania,  and  neuroses,  as  cJiorea, 
on  page  335. 

2.  Foremost  among  the  local  indications  stands  pelvic  contraction. 
This  only  applies  to  absolute  pelvic  contraction  (see  page  659),  as  the 
operation  has  no  place  in  relative  pelvic  contraction  unless  the  latter 
be  complicated  by  other  maternal  or  fetal  conditions  demanding 
emptying  of  the  uterus.  In  instances  of  absolute  pelvic  contraction 
the  choice  lies  between  induction  of  abortion  and  Caesarean  section, 
and  in  view  of  the  excellent  results  attending  the  latter  operation,  it 
should  be  the  operation  of  choice  in  these  cases,  unless  other  compli- 
cations exist  (see  page  659).  Induced  abortion  has  no  place  in  un- 
complicated ovarian  tumors,  as  we  know  to-day  that  such  tumors  can 
be  removed  by  laparotomy  without  interrupting  pregnancy,  and  this 
should  be  the  treatment  as  soon  as  the  diagnosis  of  the  tumor  is 
made  (see  page  604),  In  instances  of  uterine  myomata  complicating 
pregnancy,  likewise,  induced  abortion  rarely  is  indicated,  as  unless 
such  tumors  present  urgent  pressure  symptoms  pregnancy  should  be 
allowed  to  proceed  to  viability  or  term,  and  a  hysterectomy  per- 
formed either  after  spontaneous  labor  or  Caesarean  section,  the  latter 
operation  being  possibly  demanded  by  the  tumor  acting  as  an  obstacle 
to  delivery  through  the  pelvis  (see  page  604).  Therapeutic  abortion 
is  strictly  contraindicated  in  cancer  of  the  uterus.  If  the  case  is  oper- 
able, immediate  total  hysterectomy  is  the  operation  of  choice;  disre- 
garding entirely  the  existence  of  pregnancy.  In  inoperable  cases 
pregnancy  should  be  permitted  to  continue  to  viability  or  full  term, 
and  delivery  completed  according  to  the  indications.  In  cancer  of  the 
cervix  palliative  measures  in  the  interest  of  both  mother  and  child 
may  be  resorted  to  during  pregnancy  (see  page  610). 

Irreducible  uterine  displacements,  as  retroflexion,  prolapse,  and  hernia 
of  the  pregnant  uterus,  do  occasionally  require  therapeutic  abortion  (see 
pages  278  and  281).  Hemorrhage  in  the  middle  third  of  gestation  may 
merely  antedate  a  spontaneous  abortion,  but  when  such  bleeding  per- 
sists to  an  alarming  extent  without  the  expulsion  of  the  uterine  con- 


I     f] 


Fig.    1066. — Sterile   Solid   Bougie,    for    the    Induction    of    Premature 
Labor,   Contained  in  Sealed  Glass  Tube. 


890  OBSTETRIC  SURGERY, 

tents  therapeutic  abortion  is  required,  as  the  cause  of  the  hemorrhage  is  prob- 
ably a  placenta  prcevia  or  the  premature  separation  of  a  normally  situated  placenta 
(accidental  hemorrhage). 

Induction  of  abortion  and  irrigation  of  the  uterine  cavity  is  always  demanded 
in  those  cases  of  unsuccessful  attempts  at  criminal  abortion,  in  which  there 
is  hemorrhage  and  possibly  symptoms  of  sepsis  as  well  (see  page  360).  The 
same  may  be  said  of  instances  of  missed  abortion,  as  soon  as  the  symptoms  of 
the  death  of  the  fetus  can  be  determined  (see  page  358).  Hydatidiform  mole  (see 
page  201)  and  acute  hydramnios  (see  page  208)  are  also  indications  for  the 
induction  of  abortion. 

Indications  for  the  Induction  of  Premature  Labor. — These  are  principally 
on  account  of  some  condition  or  disease  of  the  mother,  as  contracted  pelvis  or 
pregnancy  toxemia,  or,  less  frequently,  because  of  some  pathological  condition 
existing  in  the  ovum,  as  placenta  prsevia  or  habitual  death  of  the  fetus. 

Endless  discussion  has  arisen  regarding  the  advisability  of  .this  operation  in 
contracted  pelves,  several,  as  Pinard,  Bar,  and  J.  W.  Williams,  going  so  far  as 
entirely  to  abandon  the  operation  for  this  indication,  and  they  permit  their  cases 
of  relatively  contracted  pelves  to  go  to  term  and  then  rely  upon  spontaneous 
labor,  symphyseotomy,  or  Ccesarean  section  for  delivery.  This  opinion  is 
largely  based  upon  the  difficulty  of  determining  with  accuracy  the  comparative 
size  of  the  fetal  head,  and  of  predicting  whether  sufficient  plasticity  of  the  head 
and  strong  uterine  contractions  will  be  present  in  a  given  case.  From  this 
opinion  I  most  strongly  dissent,  for  reasons  already  set  forth  in  the  Treatment 
of  Pelvic  Deformity  (page  660),  and  especially  because  pelvimetry'-  and  cephalo- 
metry  have  in  the  past  few  years  made  such  great  strides  toward  accuracy  that 
we  can  to-day  draw  very  definite  conclusions  by  our  different  methods  of  exam- 
ination, concerning  the  relative  size  of  a  given  pelvis  and  the  fetal  head.  (See 
Pelvimetry  and  Cephalometry,  pages  167  and  180.) 

Pernicious  anemia  occurs  with  greater  frequency  in  the  pregnant  woman 
than  in  the  non-pregnant,  although  it  is  a  very  rare  accident  of  gestation.  Left 
to  itself,  pernicious  anemia  tends  to  terminate  in  premature  labor  or  fetal  death 
with  eventual  death  of  the  mother.  As  this  affection  usually  appears  when 
pregnancy  is  well  advanced,  an  opportunity  is  afforded  to  aid  the  chances  of 
both  mother  and  child  by  intervening  soon  after  the  diagnosis  is  made.  The 
loss  of  blood  will  be  considerably  less  than  at  term,  and  this  fact  alone  is  suffi- 
cient to  establish  the  indication.  The  mother  is  known  to  have  recovered  in  at 
least  one  such  case.* 

Pregnancy  Toxemia. — The  mild,  often  self-limited,  type  of  toxemia  does  not 
always  call  for  the  interruption  of  labor.  When  this  condition  does  not  yield 
to  treatment,  and  when  the  clinical  picture  is  that  of  the  acute  or  fulminant 
type,  however,  labor  cannot  be  induced  too  soon.  When  the  preeclamptic 
state,  representing  as  it  does  a  severe  but  not  necessarily  pernicious  form  of 
toxemia,  does  not  subside  or  markedly  improve  under  treatment,  induced  labor 
is  indicated.  In  acute  and  chronic  nephritis,  even  if  the  toxic  symptoms  can  be 
held  in  control  by  suitable  diet,  hygiene,  and  medication,  it  must  be  remem- 
bered that  eventually  spontaneous  premature  labor  is  almost  certain  to  result, 
and  that  the  fetus  of  such  a  mother  is  usually  very  poorly  developed,  and  not 
likely  to  survive.  There  is  always  the  likelihood  in  the  continuance  of  preg- 
nancy of  acute  nephritis  becoming  chronic  and  of  chronic  nephritis  rapidly  pro- 
gressing, hence  in  the  event  of  toxic  symptoms  or  renal  insufficiency  in  these 
*Stieda:    "Ctbl.  f.  Gynakol.,"  1897. 


INDUCTION  OF  ABORTION  AND  PREMATURE  LABOR.         891 

cases,  labor  should  be  induced  solely  in  the  interests  of  the  mother,  those  of  tlie 
fetus  being  ignored. 

In  the  acute  infectious  diseases,  as  typhoid,  pneumonia,  and  in  the  acute 
exanthemata,  spontaneous  premature  labor  will  often  occur,  but  induction  of 
labor  is  contraindicated,  as  nothing  is  gained  for  the  child,  and  the  prognosis  for 
the  mother  is  not  bettered. 

Pulmonary  tiihsrcttlosis  occasionally  demands  the  operation  (see  page  331). 
For  the  induction  of  labor  in  hydatidijorm  mole,  see  page  201 ;  in  hydramnios, 
page  205  ;  placenta  prcevia,  page  222  ;  in  cardiac  disease,  page  325;  and  in  chona, 
page  335- 

At  one  time  induction  of  premature  labor  was  frequently  resorted  to  in 
instances  of  uterine  and  ovarian  tumors.  This  is  no  longer  justifiable  nor  proper 
(see  page  604). 

In  rare  instances,  from  the  thirty-fourth  to  the  thirty-eighth  week,  death  of 
the  fetus  has  occurred  in  successive  pregnancies  in  women  in  whom  nephritis 
and  syphilis  are  absent  as  causative  factors.  Although  the  cause  of  this  habitual 
death  of  the  fetus,  as  it  is  termed,  is  unknown,  it  is  justifiable  to  induce  labor  a 
week  or  so  before  the  time  at  which  fetal  death  occurred  in  previous  pregnancies, 
in  the  hope  of  securing  a  living  child.     The  procedure  is  occasionally  successful. 

In  2200  hospital  cases  I  found  it  was  necessary  to  induce  labor  in  19  cases, 
or  0.86  per  cent.,  or  once  in  11 5.8  cases.  The  indications  were:  eclampsia,  4 
cases;  albuminuria,  4;  pelvic  deformity,  4;  placenta  praevia,  i;  cardiac  disease, 
i;  shoulder  presentation,  i;  pulmonary  tuberculosis,  i ;  death  of  fetus,  i.  The 
maternal  mortality  was  in  the  19  cases,  as  was  the  fetal  mortality  after  the 
thirtieth  week,  nil.    In  one  still-birth  the  operation  was  performed  for  dead  fetus. 


METHODS  OF  INDUCING  ABORTION  AND  PREMATURE  LABOR. 

Various  drugs  have  been  used;  e.  g.,  ergot,  quinin,  pilocarpin,  ustilago 
the  oils  of  tansy,  pennyroyal,  rue,  savine  and  parsley,  sulphate  of  magnesia 
and  various  irritant  cathartics.  Many  of  these  drugs  are  dangerous  and  all 
are  unreliable.     They  act  chiefly  by  causing  congestion  of  the  pelvic  viscera. 

The  vaginal  douche  or  tampon,  the  intrauterine  injection  of  water  or  glycerin, 
the  artificial  rupture  or  circular  detachment  of  the  membranes,  and  the  use  of 
electricity,  are  either  too  uncertain  or  dangerous  as  methods  for  the  induction 
of  labor,  and  have  been  to-day  i  uperseded  by  more  reliable  and  safer  methods. 

Manual  and  Instrumental  Dilatation  of  the  Os. — Manual  or  instrumental 
dilatation  of  the  cervix  may  of  itself  be  sufficient  to  cause  the  premature  inter- 
ruption of  labor,  and  it  is  a  necessary  part  of  many  of  the  operations  designed 
for  that  purpose  (Figs.  1071  to  1093).  Since,  however,  it  is  also  a  part  of  the 
treatment  of  difficult  labor,  and  is  in  itself  a  distinct  and  important  part  of 
obstetric  surgery,  which  merits  separate  attention,  it  will  be  considered  by 
itself.     (See  page  895.) 

Catheterization  of  the  Uterus  (Krause's  Method) . — The  vagina  and  cervix  are 
carefully  disinfected.  A  solid  bougie  (No.  17  French  or  12  English)  is  disin- 
fected by  boiling  or  steaming  (Fig.  1066).  The  patient  being  in  the  lithotomy 
position,  one  or,  if  possible,  two  fingers  of  the  operator's  left  hand  are  passed 
into  the  cervix,  which  has  been  drawn  down  by  a  volsella  forceps  (Fig.  1067). 
The  bougie  is  passed  by  the  right  hand  under  the  guidance  of  the  fingers  in 
the  cervix,  between  the  membranes  and  the  uterine  wall  posteriorly,  or  in 
the  direction  of  the  least  resistance,  great  care  being  taken  not  to  rupture  the 


892 


OBSTETRIC  SURGERY. 


membranes  or  to  separate  the  placenta  (Fig.  1067).  The  bougie  should  be 
inserted  to  within  a  short  distance  of  the  fundus.  Another  bougie  may  be 
passed,  if  its  introduction  is  easy,  and  a  light  vaginal  packing  of  gauze  will  hold 
the  bougie  or  bougies  in  place  and  protect  the  vaginal  wall.  The  bougie  is 
left  to  remain  until  labor  is  well  under  way.  Labor  usually  begins  in  from 
twelve  to  twenty-four  hours.  In  introducing  the  bougie  after  the  forma- 
tion of  the  placenta  has  occurred,  care  must  be  taken  to  avoid  separation  of 
the  latter,  desisting  from  pressure  and  passing  the  bougie  in  another  direction 


Fig.   1067. — Introduction  of  a  Sterile  Solid  Bougie  into  the  Uterine  Cavity  for 
THE  Induction  of  Premature  Labor. 


if  resistance  or  hemorrhage  is  encountered.  After  introduction  of  the  bougie 
the  patient  should  remain  in  bed  until  uterine  contractions  begin.  Now  and 
then  there  will  be  a  case  in  which  active  labor  pains  will  not  begin  in 
twenty-four  hours,  and  then  the  tampon  and  bougie  should  be  withdrawn,  a 
vaginal  douche  given,  and  a  new  bougie  inserted  in  a  position  opposite  to  the 
first.  Although  one  introduction  is  generally  sufficient,  several  are  sometimes 
required  to  produce  the  desired  result,  and,  indeed,  this  method  in  certain  cases 
fails  altogether,  though  in  general  when  time  is  not  an  object  it  is  to  be  chosen 


INDUCTION  OF.  ABORTION  AND  PREMATURE  LABOR.         893 


as  the  best  and  safest.  Its  chief  danger  is  sepsis,  and  this  is  to  be  obviated 
by  the  most  rigid  antiseptic  precautions.  I  am  accustomed  to  combine  Krause's 
bougie  method  with  a  gauze  packing  of  the  lower  part  of  the  uterus.  The  gauze, 
iodoform  or  plain,  is  rapidly  run  into  the  uterus  after  the  introduction  of  the 
bougie  with  one  of  the  modern  cannula  packers  (see  Fig.  1069)  until  slight  resist- 
ance occurs.  Vaginal  packing 
is  then  accomplished  with  the 
same  instrument,  by  simply 
withdrawing  the  end  of  the  can- 
nula from  the  os  and  continuing 
the  packing  in  the  vagina.  I 
have  never  known  this  combined 
method  to  fail  to  induce  labor 
within  twelve  hours. 

Tamponade  of  the  Vagina 
and  Cervix. — The  above  method 
may  be  made  considerably  more 
effective  by  a  preliminary  tam- 
ponade  of   the    cervix.      After 

about  the  thirtieth  week  artificial  dilatation  is  not  usually  necessary.  Before  that 
time  the  cervix  may  be  dilated  by  Hegar's  dilators  or  by  the  cautious  use  of  one 
of  the  branched  dilators  until  it  will  admit  the  finger.  The  cervix  should  then  be 
packed  with  gauze  and  the  vagina  tamponed.     (Compare  page  884.) 


Fig.  1068. — Management  of  Inevitable  Abor- 
tion. Packing  the  Cervical  Canal  and  Va- 
gina WITH  Sterile  Gauze. 


Fig    1069. — Induction  of  Abortion  by  the  Introductiox  of  Sterile  Gauze  into  the 
Uterus  with   a  Cannula   Packer. 


Tamponade  of  the  Uterine  Cavity. — This  method  acts  in  the  same  way  as 
catheterization  of  the  uterus,  but  affords  a  greater  source  of  irritation  and  is 
very  likely  to  prove  effective.  The  cervix  is  dilated  if  necessar3%  and  then,  by 
means  of  a  uterine  packer,  a  tube  through  whose  lumen  a  strip  of  gauze  is 
pushed  by  a  carrier  (see  Fig.  1068),  a  quantit}^  of  sterile  gauze  is  forced  between 


894 


OBSTETRIC  SURGERY. 


the  membranes  and  the  uterine  walls  (Fig.  1069).  The  membranes  separate  with- 
out rupture,  as  the  pressure  exerted  upon  them  by  the  mass  of  gauze  is  dis- 
tributed over  a  considerable  area.  Unlike  the  bougie,  the  gauze  cannot  be 
introduced  up  to  the  fundus. 

Hydrostatic  Bags  of  de  Ribes. — An  excellent  method  for  the  induction  of 
both  abortion  and  premature  labor  is  the  introduction  into  the  lower  portion 
of  the  uterus  of  a  Champ etier  de  Ribes  bag,  or,  better,  one  of  its  numerous 
modifications  (Figs.  1093  and  1070).  A  certain  amount  of  preliminary  dilata- 
tion of  the  cervical  canal  is  a  necessity  in  this  method.     (Compare  page  904.) 

Methods  Advised  in  Early  Abortion  of  the  First  Third  of  Gestation. — Rapid 
method:   The  patient  should  be  anesthetized  and  placed  upon  a  table.     After 
careful  disinfection  of  the  external  genitals  and  vagina  the  anterior  lip  of  the 
cervix  is    grasped    by  a  volsella    forceps   and    steadied  by  an  assistant.     The 
cervix  is  then  dilated  by  Hegar's  dilators  or  one  of  the  branched  dilators  until 
it  will  admit  the  finger,  which  is  then  passed  through  the  cervix  while  the  ex- 
ternal hand  grasps  the  uterus 
through  the  abdominal  wall 
and  forces  it  downward  in  the 
axis    of    the    inferior    strait. 
The  desideratum   is  the  re- 
moval    of    an    intact   ovum, 
/  \  ''  which  cannot  always  be   ac- 

complished. An  exaggerated 
lithotomy  position  and  ab- 
dominal pressure  are  of  the 
greatest  assistance.  If,  how- 
ever, the  finger  cannot  be 
passed  high  enough  to  detach 
the  ovum,  an  effort  may  be 
made  to  detach  it  by  cau- 
tiously passing  a  dull  curette 
between  it  and  the  uterine 
wall,  when  it  may  be  removed 
by  the  finger  or  ovum  forceps. 
If  this  cannot  be  done,  it 
should  be  broken  up  and  re- 
moved by  the  curette.  (The 
technique  of  manual  and  instrumental  curettage  is  described  later.)  The 
uterus  should  then  be  carefully  but  thoroughly  curetted  with  the  sharp 
curette  and  washed  out  with  a  non -toxic  antiseptic  solution,  decinormal 
salt  solution,  or  boiled  water.  If  the  operation  has  been  aseptically  per- 
formed, gauze  drainage  is  superfluous.  Some  operators  prefer  to  remove  the 
fetus  and  then  tampon.  If  after  twenty-four  hours  the  rest  of  the  ovum  does  not 
come  away  when  the  tampon  is  taken  out,  they  curette.  As  a  rule,  it  is  well 
for  a  good  operator  to  curette  at  the  first  sitting.  It  should  be  remembered 
that  in  speaking  of  an  intact  ovum  I  mean  simply  that  the  bulk  of  the  ovum 
has  not  been  broken  up.  It  is  probable  that  complete  separation  of  the  decidua 
vera  never  takes  place.  For  this  reason  the  use  of  the  curette  is  indicated  even 
when  the  so-called  intact  ovum  has  been  removed  by  the  finger.  Slow  method: 
If  the  physician  has  not  the  necessary  instruments  or  mistrusts  his  ability  or 
operative  skill,  catheterization  of  the  uterus  may  be  tried,  or  the  ovum  may  be 
circularly  detached  with  the  sound,  or  the  cervix  and  vagina  may  be  tamponed. 


/ 


Fig.  1070. — Induction  of  Abortion  with  a  Modifica- 
tion OF  Champetier  de  Ribes'  Hydrostatic  Bag. 


MANUAL  DILATATION   OF   THE  CERVIX.  895 

or  the  last  two  expedients  may  be  used  together.  A  satisfactory,  safe,  and 
fairly  prompt  method  is  to  place  the  patient  in  the  lithotomy  position,  and 
after  strict  asepsis  of  vulva  and  vagina,  retract  the  perineum,  seize  the  anterior 
lip  of  the  cervix  with  a  volsella  forceps,  slowly  dilate  the  os  with  Hegar's 
or  a  branched  dilator  until  it  admits  the  smaller  gauze  packer,  and  then  pack 
the  uterine  cavity  with  plain  sterile  or  iodoform  gauze  until  resistance  is  en- 
countered, and  after  packing  the  vagina  apply  a  T-bandage  (Fig.  1069).  Separa- 
tion and  expulsion  of  the  ovum  into  the  upper  part  of  the  vagina  usually  occur 
within  twelve  hours.  It  is  best  to  follow  the  expulsion  of  the  ovum  with  curet- 
tage.    For  the  introduction  of  the  gauze,  anesthesia  is  usually  unnecessary. 

Method  Advised  in  Late  Abortions  of  the  Middle  Third  of  Gestation. — After 
the  third  month,  owing  to  the  development  of  the  supravaginal  portion  of 
the  cervix  and  the  commencing  formation  of  the  lower  uterine  segment,  forcible 
dilatation  without  preliminary  treatment  is  to  be  avoided.  Catheterization  of 
the  uterus  under  strict  asepsis,  combined  with  the  intrauterine  tampon,  is 
probably  the  best  treatment.  At  this  time  the  expulsion  of  an  intact  ovum 
is  not  to  be  expected.  It  is  neither  practicable  nor  safe  to  remove  a  retained 
placenta  with  the  curette.  It  should  be  done  with  the  fingers.  The  curette, 
however,  is  best  adapted  to  the  removal  of  the  decidua.  (See  Management 
of  Abortion,  page  358.)  (Compare  accouchement  force  and  instrumental  and 
manual  dilatation  of  the  cervix.  Part  X.) 

Method  Advised  in  the  Induction  of  Premature  Labor. — In  this  procedure 
rapidity  in  emptying  the  uterus  is  not  to  be  sought  for  except  in  cases  of  emer- 
gency, such  as  eclampsia  and  placenta  preevia.  It  is  best  to  imitate  as  closely 
as  possible  the  phenomena  of  natural  labor.  Catheterization  of  the  uterus  com- 
bined with  uterine  and  vaginal  tamponade,  or  the  insertion  of  a  Champetier  de 
Ribes  bag  or  one  of  its  modifications,  offers  the  best  means  of  exciting  uterine 
contraction.  Owing  to  the  deficient  vitality  of  premature  children,  however, 
great  care  should  be  used  to  avoid  early  rupture  of  the  membranes.  For 
the  same  reason  labor  should  not  be  allowed  to  continue  too  long  after  rupture 
of  the  membranes,  and  a  carefully  conducted  forceps  operation,  unless  contra- 
indicated,  is  less  likely  to  be  fatal  to  the  child  than  is  version.  After  uterine 
contractions  have  begun  the  natural  forces  should  be  allowed  to  complete  the 
delivery,  if  possible.  If  catheterization  with  uterine  and  vaginal  tamponade 
has  been  employed,  and  it  is  not  equal  to  the  task,  cervical  dilatation 
may  be  aided  by  the  bag  of  Champetier  de  Ribes  or  by  a  partial  manual  dilata- 
tion, and  after  rupture  of  the  membranes  the  engagement  of  the  head  and  its 
further  progress  may  be  aided  by  external  pressure  (Fig.  1167).  If  the  bags 
of  Champetier  de  Ribes  alone  are  employed,  partial  dilatation  of  the  cervdx 
must  first  be  secured  (page  902).  Occasional  traction  upon  the  tube  leading 
from  the  bag  will  often  hasten  the  onset  of  pains.  In  the  19  cases  already 
referred  to,  labor  was  induced  with  the  intrauterine  bougie  alone  in  7  cases; 
with  the  bougie  and  cervical  and  vaginal  gauze  packing  in  2  cases;  with  cer- 
vical and  vaginal  packing  in  2  cases;  with  Barnes'  bags  in  8  cases. 


III.  MANUAL  DILATATION  OF  THE  CERVIX. 

This  procedure  is  our  resource  when  a  serious  emergency,  arising  in  the 
presence  of  an  undilated  or  but  partially  dilated  cervix,  makes  immediate  de- 
livery a  necessity.  An  important  condition,  however,  should  be  noted.  Under 
no  circumstances  should  delivery  by  this  method  be  attempted  until  the  internal 


896 


OBSTETRIC  SURGERY. 


OS  has  disappeared  or  can  be  readily  made  to  disappear  (Figs.  1082  to  1085). 
Such  an  attempt  exposes  the  patient  to  the  most  imminent  danger  of  rupture  of 
the  uterus  (Fig.  782).  This  method  also  presupposes  a  certain  amount  of  dilata- 
tion, enough  to  admit  the  finger.  It  is  rarely  necessary,  however,  to  resort 
to  instrumental  dilatation  as  a  preliminary  during  the  latter  part  of  pregnancy. 
It  is  essential  to  the  success  of  this  method  that  the  dilatation  should  be  slow 
and  gradual.  Any  attempt  to  overcome  the  resistance  of  the  cervix  by  sudden 
force  is  likely  to  be  attended  by  consequences  of  a  most  disastrous  nature. 
As  soon  as  the  cervix  is  felt  to  contract  around  the  finger,  all  efforts  at  dilatation 
should  cease,  to  be  resumed  when  it  is  felt  to  relax.  The  operator  should 
remember  that  the  cervix  is  a  muscular  organ  and  that  its  relaxation  can  but 
gradually  be  effected,  and  that  the  physiological  softening  caused  by  the  alternate 
advance  and  retreat  of  the  presenting  part  (Fig.  565)  is  absent. 

Unimanual  Dilatation. — It  is  not  necessary  to  describe  the  various  and  prac- 
tically unessential  differences  in  the  operation  as  practised  by  different  operators 


Fig.   1071. 


-Unimanual  Dilatation  of  the 
Parturient  Os. 


Fig.   1072. — Unimanual    Dilatation  of 
THE  Parturient  Os. 


and  described  in  different  text-books.  The  method  described  by  Harris  is  the 
best  of  this  variety  of  dilatation.  The  methods  are  practically  the  same,  and 
are' all  based,  I  believe,  upon  an  erroneous  idea  of  the  mechanism  of  cervical 
dilatation.  Operation:  Perhaps  the  following  will  serve  as  an  average  descrip- 
tion of  the  method  as  commonly  used:  One  finger  is  passed  into  the  os,  and 
this  is  followed  by  the  gradual  insertion  of  the  other  fingers  successively,  finally 
of  the  thumb,  and  later  by  the  expansion  of  the  hand  (Figs.  1071  and  1072). 
When  the  closed  fist  can  be  withdrawn  through  the  os,  the  operation  is  regarded 
as  complete.  It  will  be  observed  that  in  this  operation  the  natural  method 
of  dilatation  is  reversed,  the  dilatation  during  the  greater  part  of  the  operation 
being  from  below  upward  rather  than  from  above  downward.  Some  advocates 
of  this  method  advise  that  after  the  closed  fist  has  passed  through  the  internal 
OS  it  should  be  drawn  down  at  intervals  against  the  resisting  cervical  ring  in 
imitation  of  the  advance  and  recession  of  the  fetal  head  during  natural  delivery, 
also  that  when  the  closed  fist  can  be  drawn  through  the  canal  the  highest  attain- 
able degree  of  dilatation  has  been  reached.     It  is  apparent,  however,  that  the 


MANUAL  DILATATION   OF   THE  CERVIX. 


897 


Fig.  1073. 


Fig.  1074. 


Fig.  1075. 


Fig.  1076. 


\ 


57 


Fig.  1077.  Fig.  107S. 

Figs.  1073-1078. — Bimanual  Dilatation  of  the  Parturient  Os. 


898 


OBSTETRIC  SURGERY. 


size  of  the  closed  fist  is  a  variable  quantity,  and  that  it  is  by  no  means  a  standard 
of  the  degree  of  dilatation  attainable  by  the  bimanual  method  about  to  be 
described.  It  also  seems  likely  that  the  presence  of  the  closed  fist  above  the 
internal  os  would  tend  to  displace  the  presenting  part,  and  it  is  also  more  liable 
to  injure  the  vulnerable  lower  uterine  segment  than  are  the  tips  of  the  fingers 
as  used  in  the  bimanual  method  (Figs.  107 1  and  1072). 

Bimanual  Dilatation. — The  method  to  be  now  considered  will  perhaps  be 
better  appreciated  by  a  glance  at  the  accompanying  illustrations  than  by  any 
written  description.  (Figs.  1073  to  1080.)  Like  all  methods  of  manual  dilata- 
tion it  must  be  preceded,  when  necessary,  by  some  degree  of  dilatation  obtained 
by  one  of  the  steel  instruments,  or  by  a  tampon  of  gauze  packed  into  the  uterus 
and  cervix.  This  preliminary  treatment  is,  of  course,  more  important  during 
pregnancy  than  during  labor.  In  all  cases  care  should  be  taken  that  the  pressure 
applied  in  dilatation  is   applied  to  the  internal  os,   especially  in  those  cases 

already  mentioned  in  which 
this  has  not  been  effaced. 

Indications. — In  placenta 
prcEvia  there  is  usually  such 
slight  resistance  to  be  over- 
come that  one  may  proceed 
at  once  to  dilate  with  the 
fingers.  If  hemorrhage  be- 
comes severe,  bipolar  ver- 
sion by  the  Braxton-Hicks 
method  may  be  done,  and 
while  the  fetal  leg  is  held  by 
an  assistant,  hemorrhage  be- 
ing thus  controlled,  biman- 
ual dilatation  may  be  con- 
tinued until  a  sufficient  de- 
gree of  dilatation  is  reached 
to  permit  extraction  (Fig. 
1080).  Here  the  bimanual 
method  possesses  a  marked 
advantage  over  all  others. 
Indeed,  it  is  the  only  method 
which  is  not  rendered  im- 
practicable by  the  pressure  in  the  cervical  canal  of  the  fetal  thigh  or  half  breech. 
In  eclampsia  in  pregnancy  or  labor  when  dilatation  and  softening  have  not  com- 
menced, preliminary  treatment  of  the  cervix  will  be  necessary,  and  in  the  mean 
time  such  medicinal  treatment,  in  the  way  of  elimination,  etc.,  as  may  be  neces- 
sary should  be  continued.  If  labor  has  begun  and  the  cervix  is  already  partially 
dilated,  manual  dilatation  can  be  at  once  instituted.  Manual  dilatation  may  also 
be  found  useful  in  cases  in  which  sudden  death  of  the  mother  renders  post-mortem 
delivery  necessary,  as,  for  example,  in  cases  of  maternal  apoplexy  or  cardiac  dis- 
ease, in  intrauterine  asphyxia  of  the  fetus  from  any  cause,  in  faulty  presentations 
and  positions,  in  prolapse  of  the  cord,  in  delayed  first  stage,  cervical  rigidity, 
uterine  inertia,  etc. 

I  believe  that  there  is  one  use  of  bimanual  dilatation  which  is  too  often 
neglected;  namely,  its  employment  in  the  treatment  of  delayed  first  stage  with 
reference,  not  to  immediate  delivery,  but  to  the  acceleration  of  labor.  When 
delayed  labor  is  due  to  reflex  causes, — i.  e.,  fear,  excitement,  pain,  hysteria. 


Fig.  1079. — Bimanual  Dilatation  of  the  Partu- 
rient Os. — {From,  a  photograph  taken  at  the  Emer- 
gency Hospital.) 


MANUAL  DILATATION   OF   THE  CERVIX. 


899 


etc., — a  short,  deep  anesthesia  accompanied  by  partial  manual  dilatation  is 
often  followed  by  the  happiest  results.  The  temporary  use  of  chloroform  to 
the  obstetric  degree,  however,  or  perhaps,  better  still,  the  use  of  chloral,  is 
usually  sufficient  in  these  cases.  It  is,  moreover,  useful  in  cases  in  which,  owing 
to  a  faulty  direction  of  the  uterine  axis  or  some  slight  departure  from  the  normal 
mechanism,  cervical  dilatation  does  not  progress  satisfactorily.  In  these  cases 
a  partial  manual  dilatation  is  often  followed  by  a  rapid  and  satisfactory  com- 
pletion of  labor.     When  used  in  this  manner,  manual  dilatation  is  not  to  be 


Fig.  [oSo. — Bimanual  Dilatation  of  the  Parturient  Cervix,  Carried  on  after  thb 
Bringing  down  of  One  Leg  by  Braxton  Hicks'  Method  of  Bipolar  Version, 
for  Placenta  Pr^evia. 


regarded  as  an  interference  with,  but  rather  as  an  assistance  to,  the  natural 
process  of  labor. 

Advantages. — The  advantages  of  the  bimanual  method  I  believe  to  be  the 
following:  (i)  It  is  a  closer  imitation  of  the  natural  process  of  cervical  dilata- 
tion than  are  any  of  the  other  methods  which  are  available  when  immediate 
delivery  is  necessary.  The  preliminary  dilatation  and  partial  softening  of 
the  cervix  by  the  use  of  the  cervical  tampon  or  hydrostatic  bag  causes  an 
even  closer  approach  to  the  natural  process.  (2)  The  membranes  are  pre- 
served throughout  the  operation  or  until  a  full  dilatation  is  obtainable.  (3) 
There  is  no  interference  with  the  original  presentation  and  position.  (4) 
The    sense    of   touch    of   the  operator's    fingers    is   unimpaired.     (5)  There    is 


900 


OBSTETRIC  SURGERY. 


no  constriction  of  the  operator's  hands.  (6) 
can  be  better  estimated,  and  hence  there  is 
(7)  In  placenta  prsevia  there  is  less  preliminary 
separation  of  the  placenta  by  this  method  than 
by  any  other.  (8)  There  is  less  danger  of  sepsis 
and  of  injury  to  the  lower  uterine  segment  be- 
cause of  the  limited  amount  of  manipulation 
within  the  uterus.  (9)  It  can  be  performed 
with  a  presenting  part,  as  the  leg,  in  the  os 
(Fig.  1080). 


The  amount  of   force  exerted 
less    likelihood    of  lacerations. 


Fig.  1081. — Dangers  of  a  Rapid  Breech  Extraction 
THROUGH  an  IMPERFECTLY  DiLATED  Os.  The  exter- 
nal OS  not  being  fully  dilated  or  paralyzed,  traction 
on  the  legs  or  breech  results  in  extension  of  the  head 
and  both  arms  above  the  cervix. 


Fig.  1082. — Cervical  Canal 
OF  THE  Fourth  Month  of 
Pregnancy  Unchanged. 


Operation. — The  patient  is  placed  in  the  lithotomy  position,  the  index-finger 
of  one  hand  is  introduced  within  the  cervix,  which  is  drawn  upward  behind  the 

symphysis.  (Figs.  1079  and  1073.)  When 
the  dilatation  is  sufficient  to  permit  the  in- 
troduction of  the  tip  of  the  other  forefinger, 
this  is  introduced  opposite  its  fellow  and 
pressure  is  made  by  both  fingers  in  opposite 
directions  (Fig.  1074).  A  sterile  towel  drawn 
tightly  across  the  perineum  and  pinned  to 
a  sheet  covering  the  abdomen  on  either  side 
will  prevent  contact  of  the  unused  fingers  of 
the  lower  hand  with  the  anus.  This  pressure 
is  continued  as  a  sort  of  eccentric  massage, 
the  fingers  of  the  opposite  hands  always  mak- 
ing gentle  and  steady  pressure  outward  and 
downward  and  in  opposite  directions.  The 
pressure,  at  first  made  antero-posteriorly,  is 
subsequently  made  laterally  and  obliquely, 
the  points  on  which  the  force  is  exerted  being  constantly  changed  so  that  all  parts 
of  the  cervical  ring  are  in  turn  subjected  to  it  (Fig.  1076).    As  dilatation  progresses 


Fig.  1083. — Cervical  Canal  of  a 
Primipara,  with  Beginning  Di- 
latation of  the  Internal  Os. 
I,  Internal  os;  2,  external  os. — 
(Leopold.) 


MANUAL  DILATATION  OF  THE  CERVIX. 


901 


the  second  finger  of  the  right  hand  is  introduced  alongside  of  the  first,  then  the 
second  of  the  left  hand,  as  shown  in  the  illustrations,  and  progressive  pressure 
continued  as  already  described  (Fig.  1077).  After  full  dilatation  is  accomplished 
some  time  should  be  spent  in  producing  complete  relaxation  and  paralysis  of  the 
resisting  cervical  ring  (Fig.  1078).  After  this  is  accomplished,  however,  extraction 
should  be  performed  as  quickly  as  possible,  since  the  cervix  is  likely  to  recontract. 
I  desire  to  protest  against  the  rapid  manual  dilatation  of  the  os;  namely, 
the  complete  dilatation  performed  within  an  hour,  before  the  action  of  the 
uterus  has  caused  the  cervix  to  become  relaxed,  at  least  to  a  certain  degree. 
If  the  internal  ring  is  present  and  in  a  rigid  state,  as  is  shown  in  Fig.  1082,  pre- 
liminary treatment  should  be  instituted  by  the  use  of  a  cervical  dilator  of  gauze, 
a  hydrostatic  bag,  or  the  Bossi  dilator,  that  will  induce  a  certain  amount  of  uterine 
action  with  cervical  dilatation  and  softening  and  cause  the  rings  of  the  os  to 


Fig.  1084. — Cervical  Canal  in  a  Primi- 
PARA  WITH  Beginning  Dilatation  of 
THE  Internal  Os.  Eclampsia. — (Leo- 
pold.) 


IN. OS 


S.V.C 


EX.OS. 


Fig.  1085. — Cervix  in  Latter  Part  op 
Gestation  or  at  Beginning  of  Labor. 
Vaginal  and  Supravaginal  Portions 
OF  Cervix  Unchanged,  v..  Cuff  of 
vagina;  ex.os.,  external  os  and  infra- 
vaginal  portion  of  cervix;  c.v.j.,  cervico- 
vaginal  junction;  s.v.c,  supravaginal 
portion  of  cervix;  in.os.,  internal  os; 
I.U.S.,  lower  uterine  segment. 


become  sufficiently  relaxed  so  that  rapid  dilatation  is  rendered  a  safe  operation. 
Rapid  manual  dilatation  may  be  undertaken  and  complete  paralysis  of  the 
cervix  attained  within  an  hour,  as  shown  in  Fig.  1078,  even  when  there  is  a 
minimum  amount  of  uterine  action  or  when  the  os  is  in  a  softened,  yielding, 
and  relaxing  condition,  although  the  anatomical  conditions  pictured  by  Fig. 
1084  may  exist.  A  strictly  expectant  treatment  in  respect  to  emptying  the 
uterus  is  far  preferable  to  the  attempt  quickly  to  overcome  a  rigid  os  by  manual 
means,  when  the  supravaginal  portion  of  the  cervix  still  persists  (Figs.  1082, 
1085).  To  the  writer's  knowledge  such  a  procedure  has  ended  in  complete 
rupture  of  the  uterus  followed  by  a  prolapse  of  the  maternal  intestines  between 
the  operator's  fingers  in  more  than  one  instance. 


902 


OBSTETRIC  SURGERY. 


IV.  INSTRUMENTAL  DILATATION  OF  THE  CERVIX. 

Indications. — Dilatation  of  the  os  is  a  part  of  the  induction  of  abortion 
and  premature  labor  (see  page  888).  As  a  general  rule,  it  may  be  said  that 
the  physician  should  be  slow  to  resort  to  manual  or  instrumental  dilatation 
simply  for  tedious  labor,  especially  with  unruptured  membranes.  Having  satis- 
fied himself  that  the  delay  is  not  due  to  malposition  or  malpresentation,  and 
the  condition  of  mother  and  child  does  not  require  immediate  interference, 
better  results  will  usually  be  obtained  by  the  use  of  chloral  or  a  light  temporary 
anesthesia,  and  by  an  effort  to  discover  and  remove  the  cause  of  the  delay 
(see  Anesthesia,  page  865,  and  Delayed  Labor,  page  568),  and  thus  the  mother 
will  be  saved  the  dangers  of  shock  and  sepsis  which  to  a  greater  or  less  extent 


Fig.  1086. — Instrumental  Dilatation  of  the  Parturient  Os  Preparatory  to  Further 
Manual  Dilatation,  Gauze  Packing,  the  Introduction  of  Bougies  for  the  Induc- 
tion OF  Labor,  or  Cervical  Dilators. — (From  a  photograph  of  the  author's  model.) 


attend  even  a  carefully  conducted  operation.  The  instruments  ordinarily  used 
for  producing  dilatation  of  the  cervix  are  gauze  or  metal  or  vulcanite  dilators, 
bags  of  rubber  or  silk  dilated  with  water,  and  the  hand. 

Uterine  and  Cervical  Tampon. — A  valuable  method,  although  a  slow  one,  of 
securing  cervical  dilatation  at  any  time  in  pregnancy  is  to  pack  the  lower 
uterine  segment  and  cervical  canal  with  iodoform  or  sterile  gauze  until  moderate 
pressure  is  attained.  The  packing  cannula  (Fig.  1069)  is  most  convenient  for  this 
operation.  The  vagina  is  subsequently  packed  and  a  T-bandage  applied  and  the 
gauze  left  in  for  from  six  to  twelve  hours.  This  method  I  find  invaluable  as  a 
preliminary  to  rapid  manual  dilatation  of  the  os  (see  page  902),  in  cases  of 
eclampsia,  placenta  praevia,  and  accidental  hemorrhage,  as  a  preparatory 
measure  to  cause  the  disappearance  of  the  supravaginal  portion  of  the  cervix 


INSTRUMENTAL  DILATATION   OF   THE  CERVIX. 


903 


(internal  os),  and  to  soften  the  cervix  and  the  whole  lower  uterine  segment  so  that 
the  subsequent  rapid  dilatation  can  be  easily  and  safely  accomplished. 

Graduated  Hard  Dilators. — These  are  made  of  steel  or  vulcanite  and  are 
used  in  somewhat  the  same  manner  as  uterine  sounds ;  the  smallest  being  first 
passed  into  the  cervix  and  then  the  larger  sizes  successively  until  the  dilatation 

is  deemed  sufficient.  There  are  several  var- 
ieties: Hanks',  Hegar's,  Peaslee's,  Kam- 
merer's,  etc.  Male  sounds,  Nos.  15  to  18 
French,  may  often  be  used  with  satisfaction. 
Method  and  Operation:  The  patient  is  in  the 
lithotomy  position,  the  perineum  is  retracted 
by  a  speculum.  The  anterior  and  posterior 
lips  of  the  cervix  are  drawn  down  by  volsellum 
forceps.  A  sound  shows  the  depth  and  direc- 
tion of  the  cervical  canal.  The  smallest  sound 
is  then  introduced  and  the  dilatation  carried 
as  far  as  necessary  by  the  successive  introduc- 
tion of  the  larger  ones. 


Fig.    1087. — Bossi's    Dilator    for 
THE  Parturient  Cervix. 


Fig. 


loSS. — Gau's   Dilator  for  the  Parturient 
Cervix. 


Branched  Steel  Dilators  (Fig.  1086). — This  kind  of  dilatation,  so  useful  in 
gynecological  practice,  has  hitherto  played  but  a  minor  role  in  the  department 
of  obstetrics.  The  branched  steel  dilators  heretofore  in  use  have  been  of  service 
only  in  cases  in  which  a  tightly  closed  external  os  rendered  their  use  necessary 
as  a  preliminary  to  other  methods  of  dilatation.    Dilatation  is  effected  by  passing 


904 


OBSTETRIC  SURGERY. 


the  closed  instrument  into  the  cervix  and  separating  the  branches  by  compres- 
sion of  the  handles,  applied  either  directly  by  the  hands  or  through  the 
medium  of  a  screw.  Sims'  and  EUinger's  may  be  regarded  as  types.  There 
have  been  various  modifications.  Recent  work  on  the  use  of  large  obstetric 
steel  dilators,  however,  has  opened  up  new  possibilities  in  this  direc- 
tion. One  of  the  more  recent  steel  obstetric  dilators  is  the  four-bladed  one 
of  Bossi  (Fig.  1087).  It  is  probably  the  best  instrument  now  at  our  disposal. 
Steel  instruments  are,  of  course,  more  easily  rendered  aseptic  than  is  the  hand. 
It  is  difficult,  however,  to  estimate  the  amount  of  force  used,  nor  is  a  steel  instru- 
ment so  perfectly  under  the  operator's  control.  It  is  safe  to  say  that,  as  an  imi- 
tation of  the  natural  process,  and  therefore  as  a  safe  method  of  dilatation,  no 
steel  instrument  at  present  devised  can  be  used  which  will  entirely  take  the  place 


?        '     ?^% 


Fig.  io8g. — Barnes'  Rubber  Hydrostatic  Dila- 
tor IN  Position  in  the  Cervix. 


Fig.  tooo. — The  Modified  Cham- 
petier  de  Ribes'  Hydrostatic 
Cervical  Dilator  in  Position 
in  the  LoviTER  Uterine  Seg- 
ment. 


of  the  dilating  bags  in  cases  which  permit  slow  dilatation,  or  of  the  bimanual 
method  in  cases  of  great  emergency.  Method  of  Operation:  The  position  of  the 
patient  and  the  preliminary  manipulations  are  the  same.  The  closed  branches 
of  the  dilator  are  passed  as  far  as  the  shoulders.  The  blades  are  separated  later- 
ally, then  the  instrument  is  rotated  and  they  are  separated  antero-posteriorly. 
Dilatation  should  be  very  slow  and  gradual.  Force  is  used  to  cause  the  cervix 
to  yield,  not  to  tear;  and  the  less  force  which  will  accomplish  the  purpose,  the 
better. 

Hydrostatic  Dilators. — These  are  of  rubber  or  silk,  are  hollow,  and  are  dis- 
tended after  their  introduction  by  means  of  water  which  is  forced  into  them 
with  a  Davidson  or  piston  syringe.  Barnes'  hydrostatic  dilators  have  been 
entirely  supplanted  by  the  Champetier  de  Ribes'  bag  and  its  modifications. 
The  bag  of  Champetier  de  Ribes  (Fig.  1090)  is  made  of  rubber  but  has  a  silk 


INSTRUMENTAL  DILATATION   OF   THE  CERVIX. 


905 


lining  to  prevent  bursting.  It  is  in  the  shape  of  a  cone,  the  larger  end  being 
introduced  first.  When  distended  with  water,  nature's  method  of  dilatation  is 
somewhat  closely  imitated.  This  is  especially  true  of  the  bag  of  Champetier 
de  Ribes  and  its  modifications,  and  the  colpeurynter  of  Diihrssen.  These 
well-known  instruments,  which  have  the  shape  of  a  funnel  or  an  inverted  cone, 
may  be  drawn  into  the  cervical  canal  and  against  the  internal  os  in  a  manner 
closely  simulating  the  method  of  nature.  I  regard  the  de  Ribes  bag  or  its 
modifications  as  valuable  for  the  following  reasons:  (i)  The  natural  process  is 
more  closely  imitated,  the  cervix  being  dilated  from  within  outward  according  to 


Fig.  1091. — Method  of  Grasp- 
ing THE  Modified  de  Ribes 
Bag  for  Introduction  into 
THE  Cervix. 


Fig.  1092. — Modification  of  Champetier  de 
Ribes'  Hydrostatic  Cervical  Dilators.  Two 
Sizes  Shown. 


the  natural  process.  (2)  The  bag  does  not  slip  out.  (3)  By  gentle  traction 
upon  the  tube  one  can  cause  uterine  contraction  and  assist  in  dilatation  if 
necessary.  (4)  The  bag  is  not  likely  to  burst.  (5)  It  is  a  valuable  agent  in 
prolapse  of  the  funis  or  fetal  small  parts,  in  premature  rupture  of  the  mem- 
branes, in  placenta  praevia  and  other  complications. 

Method  of  Introducing  the  Soft  Dilators. — A  certain  amount  of  dilatation  is 
presupposed.  The  dilator  should  be  folded  upon  itself,  lubricated  with  a  i  per 
cent,  lysol  solution,   seized  with  a  pair  of  long  dressing  forceps,  and  passed 


900 


OBSTETRIC  SURGERY. 


within  the  cervix  until  the  constricted  part,  if  a  Barnes  bag  is  used,  is  at  the 
internal  os,  or  until  half  the  bag,  if  a  de  Ribes  bag  is  used,  is  within  the  internal 
OS  (Fig.  1 091).  The  Barnes  bag  is  provided  with  a  pocket  into  which  a  sound  may- 
be inserted  and  the  bag  passed  into  the  cervix  with  the  sound.  The  first  method, 
however,  is  more  satisfactory.     Bags  should  not  be  distended  with  air,  since 

their  rupture  may  then  be  attended  with 
serious  consequences.  Water  should  be  used 
and  should,  of  course,  be  forced  in  slowly 
and  gradually.  In  using  the  Barnes  bag, 
when  the  smaller-sized  bag  has  been  ex- 
pelled, the  next  larger  one  should  be  in- 
serted if  necessary.  With  the  de  Ribes  bag 
no  change  is  necessary  unless  one  uses 
graduated  sizes,  which  may  now  be  obtained 
of  the  instrument -makers  in  New  York.  In 
every  instance  when  a  hydrostatic  cervical 
dilator  is  used,  the  bag  should  be  carefully 
tested  before  introduction.  This  is  done  by 
forcing  a  given  number  of  bulbfuls  of  water 
from  a  Davidson  syringe  into  the  bag  so  as 
fully  to  distend  it;  then,  if  the  bag  remains 
intact,  it  is  introduced  and  to  insure  against 
rupture  one  bulb  less  of  water  is  pumped  in 
than  in  the  test  examination.  I  have  in 
two  instances  seen  rupture  of  the  uterus, 
as  proved  by  autopsy,  caused  by  the  intra- 
uterine explosion  of  an  overdistended  Barnes 
bag.  The  large  Champetier  de  Ribes  dila- 
tors, as  originally  sold,  should  be  avoided,  and 
only  the  smaller  ones  used.  The  former  occupy  too  much  space  in  the  lower 
uterine  segment,  change  its  shape,  and  favor  malpresentation  of  the  fetus.  In 
my  practice  I  observed  a  vertex  presentation  changed  thus  to  a  shoulder,  for 
which  I  was  compelled  to  perform  an  internal  podalic  version. 


CEBViX..... 


Fig.  1093. — Coe's  Modification  of 
Champetier  de  Ribes'  Hydro- 
static Cervical  Dilator. 


V.  MANUAL  AND  INSTRUMENTAL   DILATATION  OF  THE 
VAGINA  AND  VULVA. 

Indications. — Occasionally  in  very  old  or  very  young  primiparae,  in  cases 
of  cicatrices  from  previous  inflammation  and  ulceration,  in  malignant  disease 
and  thrombosis,  artificial  dilatation  of  the  vagina  may  be  demanded.  I  have 
occasionally  been  compelled  to  employ  this  operation  in  elderly  primiparae 
and  in  the  very  young.  In  cicatricial  stenosis  of  the  vagina,  dilatation  by  the 
fingers  or  hydrostatic  dilators  may  occasionally  be  required,  but  in  most  cases 
the  natural  forces  will  overcome  the  obstruction,  even  when  the  original  opening 
would  admit  but  one  finger.  In  cases  in  which  the  vagina  is  simply  small  and 
rigid — e.  g.,  in  very  young  or  in  old  primiparae — the  resistance  is  chiefly  at 
the  lower  third,  and  the  case  should  be  left  to  nature  as  long  as  is  judged  safe. 
A  carefully  conducted  forceps  operation  with  very  slow  extraction  is  then  to 
be  considered  as  the  best  means  of  effecting  further  dilatation.  If  even  this 
bids  fair  to  produce  severe  laceration,  or  if  rapid  delivery  is  imperative,  episi- 


INCISIONS  OF  THE  CERVIX,  VAGINA,  AND  VULVA.  907 

otomy  (q.  v.)  may  be  re(iuired.     In  certain  cases  of  a  small  and  rigid  vulva  and 
lower  third  of  the  vagina  surprisingly  good  results  may  be  obtained  by  manual 


) 


**««. 


Fig.  1094. — Digital   Dilatation  of  the  Vulva  in  a   Primipara. 

dilatation,  one  or  two  fingers  being  introduced  into  the  posterior  commissure 
followed  by  intermittent  backward  massage-like  pressure  (Fig.  1094). 


VI.  INCISIONS  OF  THE  CERVIX,  VAGINA,  AND  VULVA. 

I.  Superficial,  and  2.  Deep  Incisions  of  the  Cervix. — (i)  Superficial  multiple 
incisions:  These  as  well  as  deep  incisions  are  required  only  in  exceptional  cases, 
and  are  especially  liable  to  extend  and  involve  the  branches  of  the  uterine 
artery.  Superficial  incisions  or  nicks  in  the  cervix  are  indicated  only  when  the 
use  of  chloral  or  some  other  anesthetic  has  failed,  and  when  manual  dilatation 
without  the  use  of  a  dangerous  degree  of  force  does  not  succeed.  This  most 
often  occurs  in  rigidity  of  the  portio  vaginalis  in  old  primiparse,  and  in  multiparse 
when  several  years  have  elapsed  since  the  birth  of  the  last  child.  There  is 
a  lack  of  elastic  tissue,  or  atrophy  of  the  elastic  fibers  has  already  begun.  It 
may  also  be  indicated  in  cases  of  atresia  in  which  the  os  cannot  be  opened 
by  the  finger  or  dilator.  In  this  case,  if  the  os  cannot  be  located,  the  stretched 
cervix  may  be  raised  by  tenacula  at  its  thinnest  point,  and  a  crucial  incision 
made.  The  superficial  incisions  are  made  by  a  blunt-pointed  bistoury  or  a 
pair  of  blunt-pointed  scissors.  During  a  pain,  the  patient  being  in  the 
lithotomy  position,  the  instrument  is  carried  into  the  vagina  under  the 
guidance  of  the  fingers,  and  the  stretched  cervical  rim  is  incised  in  several 
places  to  the  depth  of  0.5  cm.  (Fig.  1095).  Dilatation  sometimes  occurs  with 
surprising    rapidity   after   this   procedure.     Care    should    be   taken    that    such 


908 


OBSTETRIC  SURGERY. 


incisions  are  really  superficial,  since  when  carried  further  they  are  likely  to 
extend  and  to  result  in  disastrous  lacerations  of  the  lower  uterine  segment. 
(2)  Deep  incisions:  Incisions  of  the  cervix  extending  to  the  utero-vaginal  junc- 
tion and  involving  the  entire  vaginal  portion  were  first  proposed  by  Skutsch 
and  first  performed  by  Duhrssen.  Indications:  Those  usually  given  are:  any 
emergency  which  requires  immediate  delivery  in  the  presence  of  an  undilated 


Fig.    1095. — Multiple    Superficial    In- 
cisions OF  THE  External  Os. 


Fig.  1096. — Deep  Incisions  of  the  Par- 
turient Cervix,  Extending  from  the 
Border  of  the  External  Os  to  the 
Utero-vaginal  Junction. 


and  rigid  cervix;  e.  g.,  eclampsia,  accidental  hemorrhage.  The  operation  should 
not  be  performed  until  the  supravaginal  portion  of  the  cervix  has  disappeared, — 
in  other  words,  when  the  defective  dilatation  is  confined  to  the  vaginal  portion 
of  the  cervix, — and  is,  therefore,  much  more  frequently  indicated  in  primiparag. 
In  multiparae  mechanical  dilatation  is  usually  sufficient.     In  the  presence  of 


(t 

k 


Fig.  1097. — Effect  of  the  Four  Deep 
Incisions  of  the  Cervix  upon  Dilata- 
tion. 


Fig.  logS. — Author's  Case  of  Deep 
Bilateral  Incisions  of  the  Cervix 
Thirteen  Months  after  Delivery. 
Partial  Repair  Has  Taken  Place 
IN  the  Bilateral  Incisions. 


immediate  danger,  however,  the  supravaginal  portion  still  being  present,  the 
two  procedures  may  be  combined  with  advantage;  that  is,  mechanical  dilatation 
until  the  internal  os  has  been  obliterated  and  rapid  completion  of  the  dilatation 
by  deep  incisions.     There  is  one  condition  in  which  they  should  always  be 


INCISIONS  OF   THE  CERVIX,  VAGINA,  AND   VULVA. 


909 


avoided;  namely,  in  arrest  of  the  after-coming  head  during  breech  delivery,  or 
after  version  in  multiparse.  Here  the  resistance  is  at  the  internal  os,  and  any  but 
the  most  superficial  incisions  would  be  likely  to  result  in  extension  to  uterine 
rupture  during  the  process  of  delivery.  Operation:  The  patient  being  in  the 
lithotomy  position,  the  free  edge  of  the  os  is  fixed  between  two  bullet  forceps, 
and  under  the  guidance  of  the  index  and  middle  fingers  of  the  left  hand,  one 
within  and  the  other  without  the  cervix,  the  vaginal  portion  of  the  cervix  is  in- 
cised by  a  pair  of  long,  blunt-pointed,  straight  or  angular  scissors  or  a  bistoury, 
care  being  taken  that  the  incision  is  brought  fully  up  to  the  utero-vaginal  junction. 
If  the  incision  stops  short  of  this  point,  full  dilatation  does  not  take  place  and  ex- 
tension beyond  the  vaginal  attachment  may  occur  from  tearing.  Care  should  be 
taken  that  a  fold  of  vagina  is  not  included  in  the  incision,  since  this,  in  case  of 
the  posterior  incision,  might  open  into  the  pouch  of  Douglas,  or  in  case  of  the 
anterior  incision   might  involve  the  utero-vesical  pouch  or  even  the  bladder. 


Fig.  1099. — Episiotomy.- 


■{The  face  presentation  is  from  a  photograph  of  the  author's  case 
taken  at  the  Emergency  Hospital.) 


The  same  mistake  in  the  case  of  a  lateral  incision  might  result  in  severing  a 
ureter.  Four  incisions  are  usually  made,  two  antero-posterior  and  two  lateral 
(Figs.  1096  and  1097).  Suture  is  not  necessary  except  in  case  of  severe 
hemorrhage,  which  should  not  occur  if  the  incisions  have  been  properly  made. 
Spontaneous  union  of  the  edges  usually  occurs.  The  risks  of  septic  infection 
are  the  same  as  in  any  other  internal  obstetric  .procedure.  The  field  of  this 
operation  is  most  limited.  The  operation  itself  is  a  serious  one  and  not  lightly 
to  be  undertaken.  In  all  but  exceptional  cases  rapid  bimanual  dilatation  of  the 
OS,  or  rapid  bimanual  dilatation  of  the  os  combined  with  these  incisons,  will 
fulfil  all  indications. 

Incisions  of  the  Vagina.— These  are  most  often  called  for  in  cases  of  cicatricial 
contraction  or  congenital  defects,  and  are  best  made  along  the  lateral  vaginal  wall 


910 


OBSTETRIC  SURGERY. 


with  a  blunt  bistoury.  A  comparatively  large  number  of  shallow  incisions  are 
to  be  preferred  to  a  few  deep  ones,  since  there  is  less  danger  of  hemorrhage. 
Lateral  incisions  are  to  be  preferred  to  anterio:  or  posterior  ones,  when  possible, 
since  the  latter  may  involve  important  structures — bladder,  peritoneum,  rectum. 
In  all  cases,  however,  labor  may  usually  be  terminated  either  spontaneously  or 
by  the  use  of  forceps  or  version,  with  manual  dilatation  of  the  vagina  without 
using  the  knife.  Cases  of  unyielding  circular  cicatricial  contraction  may  be 
treated  by  a  cruciform  incision. 

Incision  of  the  Vulva.  Episiotomy. — Definition:  The  operation  of  making 
lateral  incisions  in  the  vulva  in  order  to  avoid  laceration  of  the  perineum. 
Indications:  It  is  indicated  when  delivery  without  severe  perineal  laceration  is 
deemed  impossible — usually  in  cases  of  great  disproportion  in  size  between  the 
fetal  head  and  vulval  outlet.     It  is  seldom  necessary,  however,  and  in  the 

absence  of  cicatricial  contraction 
better  results  will  usually  be  ob- 
tained by  awaiting  the  natural  pro- 
cess of  dilatation.  Operation:  The 
operator  should  remember  that  it  is 
not  the  border  of  the  vulva  which 
resists  the  progress  of  the  head,  but 
the  tense  ring  situated  about  half  an 
inch  above.  During  a  pain  this  ring 
is  readily  recognized  about  half  an 
inch  above  the  muco-cutaneous 
junction.  The  incisions  should  not 
be  in  the  line  of  the  vulvo-vaginal 
outlet  as  it  appears  during  the  stage 
of  expulsion,  or  it  will  be  found  after 
delivery  that  they  have  been  direct- 
ed too  far  backward.-  They  should 
be  made  in  a  direction  corresponding 
to  the  long  axis  of  the  mother's  body 
as  she  lies  in  the  recumbent  position. 
Under  the  guidance  of  the  fingers  a 
blunt-pointed  bistoury  is  passed  flat- 
wise against  the  resisting  ring,  then 
turned,  and  the  ring  incised  from 
within  outward.  The  incision  should 
not  exceed  an  inch  in  length  and 
its  depth  should  be  about  a  quarter  of  an  inch.  It  should  be  made  at  a  point 
about  one-third  of  the  distance  from  the  posterior  to  the  anterior  commissure 
when  the  parts  are  on  the  stretch.  In  this  location  the  only  parts  severed  are 
the  skin,  fascia,  and  perhaps  the  bulbo-cavemosus  muscle  (Fig.  1099).  If  pre- 
ferred, the  incision  may  be  made  with  blunt-pointed  scissors  (Fig.  1099).  Care 
should  be  taken  that  the  head  is  not  suddenly  forced  out  during  the  operation. 
For  this  reason  it  is  better  that  the  incisions  should  be  made  at  the  beginning 
or  toward  the  end  of  a  pain,  and  that  the  progress  of  the  head  be  retarded  if 
necessary.  After  delivery  the  incisions  are  at  once  closed  by  suture.  In  suturing 
it  is  convenient  that  the  mother  lie  upon  the  right  side  while  the  left  incision 
is  being  sutured,  and  vice  versa.  In  this  way  the  field  of  operation  is  kept  clear 
of  blood. 

Vagino-perineal  Incision. — Diihrssen  advises  in  some  cases  of   small  and 


Fig.  1 100. — Deep  Vagino-perineal  Incisions 
FOR  Small  and  Rigid  Vagina. —  (Duhrssen.) 


CORRECTION  OF  FAULTY  POSTURE. 


911 


rigid  vaginae  in  which  immediate  delivery  is  urgent,  incisions  which  divide 
not  only  the  constrictor  cunni  but  the  levator  ani.  These  he  calls  vagino- 
perineal incisions.  He  advises  that  when  possible  only  one  incision  be  made. 
This  method  has  thus  far  not  met  with  general  approval  (Fig.  iioo). 


VII.  CORRECTION  OF  FAULTY  POSTURE,  MALPOSITIONS, 
AND  MALPRESENTATIONS. 

I.  Manual  Correction  of  Bregma,  Brow,  and  Face  Presentations. — (i)  Schatz 

External   Method:  This  method  is  limited  to  those  cases  in  which  the  head 


Pig.  iioi. — Manual  Correction  of  Brow  and  Face  Presentation.  Rotation  of  the 
head  upon  a  transverse  diameter  to  produce  flexion  with  the  internal  hand,  and  down- 
ward pressure  upon  the  occiput  with  the  external  hand.     (Baudelocque's  method.) 


is  not  engaged  and  is  freely  movable;  the  membranes  are  unruptured,  or  if 
ruptured  the  fetus  is  readily  moved  about  in  the  uterus ;  and  there  is  no  imme- 
diate demand  for  the  rapid  termination  of  labor.  The  method  is  only  exception- 
ally successful,  there  having  been  many  failures,  and  by  reason  of  the  conditions 
necessary  for  its  performance,  has  a  very  limited  field,  being  confined  mainly 
*  Thorn:  "Zeit.  fiir  Gynecol,  v.  Geburts  ,"  xiii,  i86. 


912 


OBSTETRIC  SURGERY. 


to  maternity  hospitals,  where  the  anomaHes  are  recognized  early  in  labor. 
Although  Schatz  describes  his  method  as  applicable  to  face  presentations,  from 
a  mechanical  standpoint  it  is  also  applicable  in  bregma  or  brow  presentations. 
Operation:  Anesthesia  is  not  always  required.  The  patient  is  placed  in  the 
dorsal  posture  with  knees  partly  drawn  up;  the  operator  stands  on  the  side 
toward  which  the  occiput  is  directed.  Between  uterine  contractions  one  hand 
grasps  the  breech  and  one  the  anterior  shoulder,  and  an  even,  strong  pressure 
is  made  upon  the  shoulder  toward  the  occiput  and  somewhat  upward;  the 
breech  is  at  the  same  time  pushed  upward  with  the  other  hand  and  also  toward 


Fig.  II02. — Manual  Correction  of  Face,  Brow,  and  Bregma  Presentation.  The 
internal  hand  rotates  the  head  upon  a  transverse  diameter  by  drawing  down  the  occiput, 
and  the  external  hand  pushes  the  anterior  shoulder  to  the  side  toward  which  the  dorsal 
plane  lies.     Thorn's  method.* 


the  abdominal  surface  of  the  fetus;  finally,  the  breech  is  pressed  downward. 
During  the  uterine  contractions  all  manipulations  cease  and  the  head  is  grasped 
through  the  abdominal  walls  and  fixed.  After  the  occiput  is  brought  over 
or  into  the  pelvic  inlet,  the  membranes  may  be  ruptured  and  the  head  held  until 
engagement  occurs  (Fig.  684).  (2)  Combined  External  and  Internal  Method  : 
If  the  above  method  fails,  which  is  pretty  sure  to  be  the  case,  one  of  the  following 
can  be  tried,  (a)  Digital  pressure:  In  bregma  and  brow,  and  occasionally  in 
face  presentations,  passing  two  or  three  fingers  into  the  vagina  and  pressing 
up  upon  the  bregma,  brow,  and  at  the  same  time  using  counter-pressure  with 


CORRECTION  OF  FAULTY  POSTURE. 


913 


the  whole  of  the  remaining  hand  upon  the  breech  of  the  fetus,  will  often  rotate 
the  fetal  head  upon  its  transverse  axis  (Fig.  1103).  In  this  method  the  dorsal 
posture  with  flexed  thighs  is  used  for  the  patient,  and  the  operator  stands  or, 
better,  sits  on  the  side  of  the  patient  toward  which  the  occiput  points.  (6) 
lAjting  of  the  brow  and  face:  With  the  same  positions  of  patient  and  operator, 
but  under  anesthesia,  the  hand,  the  palm  of  which  corresponds  with  the  fetal 
face,  is  passed  into  the  vagina  and  grasps  the  forehead  or  face  and  carries  it 
away  from  the  pelvic  inlet  in  the  direction  of  the  fetal  chest,  while  the  external 


Fig.  1 103. — Combined  Manual  Method  for  the  Correction  of  Face  and  Brow  Pres 

ENTATIONS.       ScHATZ-ThORN    MeTHOD. 


hand  presses  the  occiput  down,  through  the  abdominal  walls,  into  the  pelvic 
inlet  (Fig.  iioi).  Before  the  internal  hand  is  removed  the  operator  must  satisfy 
himself  that  the  large  fontanelle  is  actually  higher  than  the  small  one,  and  that 
the  vertex  is  about  to  engage.  In  difficult  cases  the  Trendelenburg  posture  will 
be  of  great  assistance.  Humphrey  used  the  knee-elbow  posture  for  the  patient, 
(c)  Drawing  down  the  occiput  {Thorn's  method) :  The  posture  of  the  patient  is 
the  same  as  above,  but  the  operator  sits  or  stands  on  the  side  toward  which 
the  fetal  abdomen  points.  The  hand,  whose  palm  would  naturally  grasp 
the  occiput,  is  passed  into  the  vagina,  and  draws  down  the  occiput  with 
58    . 


914 


OBSTETRIC  SURGERY. 


an  even  traction,  while  at  the  same  time  the  external  hand  pushes  the  chest 
of  the  fetus,  or  rather  the  shoulder,  to  the  side  toward  which  the  dorsal  plane 
lies  (Fig.  1 1 02).  The  Trendelenburg  posture  will  greatly  aid  this  manipulation, 
(d)  Combined  methods:  In  very  difficult  cases  a  combination  of  Schatz's  and 


Fig.  1 104. — Manual  Correction  of  a  Persistent  Mento-posterior  Position  by  Manual 
Anterior  Rotation  of  the  Fetal  Chest  and  Chin. 


the  method  of  drawing  down  the  occiput  by  internal  manipulation  has  been 
successful  (Fig.  11 03). 

2.  Persistent   Occipito-posterior   Position. — (See  Pathol6g>'  of  Labor,    page 

547-) 

4.  Persistent   Mento-posterior    Position. — (See    Pathology    of    Labor,   page 

550-)      (Fig-  II04-) 

4.  Reposition  of  Prolapsed  Cord.— (See  Pathology  of  Labor,  page  525.) 

5.  Reposition  of  Prolapsed  Arms  and  Legs. — (See  Pathology  of  Labor,  pages 
520  and  522.) 


THE   VECTIS—THE  FILLET. 


915 


VIII.  THE  VECTIS. 

The  vectis  was  one  of  the  simplest  forms  of  instruments  used  for  extracting  or 
changing  the  position  of  the  fetal  head;  it  antedated  the  forceps,  and  has  prac- 
tically been  abandoned  as  an  instrument  by  itself,  in  favor  of  the  forceps,  which 
has  proved  both  safer  and  more  effective.  The  principle  of  the  vectis  is  still 
used  in  obstetrics,  however,  by  utilizing  one  blade  of  the  forceps,  and  from  time 
to  time  attempts  have  been  made  to  revive  interest  in  the  value  of  the  original 
instrument.*  It  resembles  a  single  blade  of  a  pair  of  straight  forceps  except 
that  the  cephalic  curve  is  much  more  pronounced,  especially  near  the  extremity 
of  the  instrument,  in  order  to  permit  of  a  better  hold  of  the  head  (Fig.  1105). 


Fig.   1105. — The  Copeman  Vectis. 


Fig.   1 106. — The  Fillet. — (Galabin.) 


The  vectis  was  used  as  a  lever  and  a  tractor,  and  some  of  the  English  writersf 
still  recommend  its  use  in  persistent  occipito-posterior  positions  and  brow  presen- 
tations. In  the  former  case  it  was  used  as  a  combined  lever  and  tractor  to 
favor  anterior  rotation,  and  in  the  latter  as  a  tractor  to  convert  the  brow  into 
a  vertex  or  face.  I  believe  the  forceps  to  be  a  safer  and  more  efficient  instru- 
ment for  the  first  purpose,  and  the  hand  of  the  obstetrician  for  the  second. 


IX.  THE  FILLET. 

The  whalebone  fillet,  consisting  of  an  inverted  U-shaped  piece  of  whalebone 
joined  at  the  extremities  of  the  U  by  a  handle,  is  an  instrument  intended  to 
rotate  the  head  upon  its  transverse  axis,  thus  producing  either  flexion  or  exten 
sion,  as  desired,  by  traction  upon  one  pole  of  the  head  (Fig.  1106).     The  instru- 

*Bartlett,  John:  "  The  Vectis,"  "  The  Clinical  Review,"  Chicago,  Nov.,  1900. 
t  Galabin:   "A  Manual  of  Midwifery,"  London,  1900,  p.  612. 


916  OBSTETRIC  SURGERY. 

ment  antedates  the  forceps,  and  is  now,  perhaps  with  less  justice  than  the  vectis, 
considered  obsolete.  Placed  over  the  chin  to  produce  extension  of  the  head  by 
traction  on  the  handles,  the  instrument  was  liable  to  injure  the  fetus,  and  its 
hold  on  the  occiput  to  increase  flexion  of  the  head  was  always  uncertain  and  dan- 
gerous by  reason  of  the  tendency  of  the  fillet  to  slip.  As  in  the  case  of  the  vectis, 
the  hand  of  the  obstetrician  passed  into  the  vagina  combined  with  bimanual 
manipulation  will  do  all  and  more  than  the  fillet.  (See  page  911.)  The  contin- 
gency might  possibly  arise  when  in  the  absence  of  instruments  an  improvised  fillet 
of  whalebone  or  wire  could  be  used  to  flex  the  extended  head  of  a  dead  fetus, 
and  possibly  of  one  living. 


X.  REPOSITION  OF  SMALL  PARTS. 

1.  Umbilical  Cord. — (See  page  525.)     (Also  Figs.  1107  to  11 13.) 

2.  Other  Small  Parts. — If  in  the  course  of  labor  in  cranial  presentations  with 
unruptured  membranes,  some  small  part — the  hand,  for  example — prolapses,  it 
will  almost  always  be  found  at  the  facial  side  of  the  head.  Reposition  can 
usually  be  effected  by  placing  the  woman   on  the  side  opposite  that  of  the 


\ 

\ 


>\ 


Fig.    1 107. —Manual  Reposition  of  a  Prolapsed  Cord. 

prolapse,  and  when  the  head  is  allowed  to  re-engage  the  obstacle  will  be  out  of  the 
way.  (i)  In  case  the  membranes  have  ruptured  and  a  hand  or  arm  has  pro- 
lapsed, reposition  may  often  be  effected  by  a  simple  manipulation,  if  the  os  is 
fully  dilated  and  the  head  high  up.  The  woman  is  placed  in  the  latero-prone 
position  (Fig.  1051)  and  the  operator  introduces  his  hand  into  the  vagina  and 
endeavors  to  conduct  the  prolapsed  part  up  along  the  face.  The  woman  should 
lie  on  the  side  opposite  the  prolapse  until  the  head  engages.  If  this  manoeuver 
fails,  the  operator  may  sometimes  leave  the  case  to  nature.     In  a  roomy  pelvis 


REPOSITION  OF  SMALL  PARTS. 


917 


it  is  quite  possible  for  the  head  and  an  arm  to  engage  at  the  same  time.  But 
if  the  pelvis  is  contracted  or  if  an  indication  arises  to  terminate  labor  at  once, 
podalic  version  may  be  attempted  if  the  head  is  movable,  but  otherwise,  forceps 
delivery.  In  prolapse  of  a  foot  in  head  presentations,  which  is  very  rare,  the 
indications  are  similar.  (2)  Should  the  head  be  well  down  in  the  true  pelvis, 
an  expectant  treatment  should  be  followed;  and  if  any  immediate  danger 
threatens,  such  as  delayed  labor  from  obstruction  or  oedema  of  the  leg,  extraction 
of  the  head  with  the  forceps  should  be  done,  taking  care  not  to  include  the  pro- 


V 


/ 


Fig.  iro8. 


— Instrumental  Reposition  of  a  Prolapsed  Cord,  .\ssisted  by  the  Knee- 
chest  Posture  of  the  Patient. 


lapsed  leg.  Impaction  in  the  case  of  a  dead  fetus  of  course  calls  for  perforation. 
(3)  When  the  head  is  movable  at  the  pelvic  inlet  or  extra-medial  by  reason 
of  the  prolapsed  leg  filling  in  one  side  of  the  pelvis,  and  the  leg  constitutes 
an  actual  obstruction,  manual  reposition  should  be  performed.  In  any  event, 
the  existence  of  twins  must  be  borne  in  mind,  as  one  may  present  by  the  head 
and  the  other  by  the  leg  or  foot.  The  patient  is  placed  in  the  lithotomy  position 
or,  better,  on  her  side  (compare  prolapse  of  cord  and  arm),  and  the  foot  or 
knee  is  seized  with  the  whole  hand  and  pushed  upward  past  the  head;  at  the 
same  time  a  hand  on  the  fundus  presses  the  head  into  the  pelvic  inlet  from 


918 


OBSTETRIC  SURGERY. 


Fig.  1 109. — English  Catheter 
AND  Sling  for  Reposition  op 
Prolapsed  Cord. 


Fig. 


1 1 10. — English  Catheter  and  Loop  of  Tape 
FOR  Reposition  of  a  Prolapsed  Cord. 


Fig.  nil. — Simple  Long  For- 
ceps Used  to  Replace  a  Pro- 
lapsed Cord. 


Fig.   1112. — Whale-  Fig.     1113.  —  Whalebone     Re- 
bone     OR     Metal  positor    for     a     Prolapsed 
Repositor   and  Cord. 
Sling. 


REPOSITION   OF  SMALL  PARTS.  919 

without.  Anesthesia  is  necessary,  and  in  some  difficult  cases  the  exaggerated 
semi-prone,  Trendelenburg,  or  knee-chest  position  will  be  required.  After  re- 
position the  dorsal  position  will  give  as  satisfactory  results  as  either  of  the 
lateral,  provided  the  head  is  kept  applied  to  the  pelvic  inlet  by  pressure  on 
the  fundus  until  engagement  takes  place.  (4)  In  case  manual  reposition  fails 
the  head  may  be  pushed  up  and  version  and  extraction  promptly  performed, 
the  possibility  of  the  existence  of  twins,  and  of  the  presentation  of  one  by  the 
head  and  of  the  other  by  the  leg,  being  always  remembered. 


XI.  VERSION. 

Definition. — By  version  is  meant  the  changing  of  the  presentation  of  the 
fetus  so  that  one  or  the  other  of  the  two  poles  of  the  fetal  ellipse  is  substituted 
for  a  given  presentation. 

History. — Version  is  one  of  the  most  ancient  of  the  obstetric  operations, 
and  before  the  invention  and  introduction  of  the  forceps  was  used  much  more 
frequently  than  it  is  at  present.  Cephalic  version  was  the  first  variety  used,  and 
is  said  to  have  been  recommended  by  Hippocrates  and  employed  even  in  pelvic 
presentations.  Before  the  sixteenth  century  it  was  practically  the  only  version 
used,  but  at  that  time  podalic  version  was  introduced,  and  because  of  the  ease 
of  its  performance  became  very  popular,  and  on  this  account  cephalic  version 
was  almost  entirely  abandoned,  although  more  recently  revived  by  some  obstet- 
ricians. 

Classification. — Version  is  usually  classified,  first,  according  to  the  part  of 
the  fetus  which  is  caused  to  present  at  the  pelvic  inlet,  into  cephalic  version, 
podalic  version,  and  pelvic  version.  The  last  of  these,  namely,  pelvic  version, 
is  to-day  rarely,  if  ever,  performed.  Version  is  again  subdivided,  according  to 
the  mode  in  which  it  is  performed,  into  three  varieties — namely,  external  ver- 
sion, combined  external  and  internal  or  bipolar  version,  and  internal  version. 
External  version  is  performed  by  external  manipulation  only;  combined  exter- 
nal and  internal  or  bipolar  version  by  the  use  of  one  hand  introduced  into  the 
vagina  and  one  or  more  fingers  into  the  uterus  to  move  one  part  of  the  fetus, 
while  the  other  hand  upon  the  anterior  abdominal  wall  moves  another  por- 
tion of  the  fetus,  thus  assisting  the  internal  fingers.  Internal  version  is  ac- 
complished by  passing  the  whole  hand  into  the  uterus  to  grasp  some  part  of 
the  fetus,  usually  the  feet,  and  the  other  hand  is  used  on  the  abdomen  to 
steady  the  fetus  and  assist  the  internal  hand  as  far  as  possible.  (See  table  on 
page  920.) 

Frequency. — In  2200  confinements  in  New  York  hospitals  I  found  that 
version  was  performed  in  44  instances,  or  2  per  cent.,  or  once  in  50  labors. 

Indications. — In  the  44  versions  referred  to,  the  indications  were:  de- 
formed pelvis  in  II  cases;  shoulder  presentation  in  7;  shoulder  presentation 
and  prolapsed  cord  in  3 ;  persistent  occipito-posterior  position  in  2 ;  placenta 
prasvia  in  6 ;  prolapsed  cord  in  3  ;  prolapsed  cord  and  hand  in  i ;  prolapsed  hand 
in  I ;  deformed  pelvis  and  albuminuria  in  i ;  deformed  pelvis  and  shoulder  pres- 
entation in  2 ;  uterine  inertia  in  2 ;  prolapse  of  leg  in  vertex  presentation  in  i ; 
brow  presentation  in  i ;  hydrocephalus  in  i ;  albuminuria  in  i . 

Varieties. — Of  the  44  cases  analyzed,  35  were  of  the  internal  podalic  variety; 
3  bipolar;  6  not  recorded. 


920 


OBSTETRIC  SURGERY. 
CLASSIFICATION  OF  VERSION. 


Parts  CALtSED  to  Present 

Mode  of  Performance. 

Employed. 

(A)   Cephalic  Version  .  .  .  . 

1 

V 

I. 

2. 

3- 

External  Cephalic. 

Combined  External  and  Internal 

Cephalic  (Bipolar). 
Internal  Cephalic. 

Occasionally. 
Occasionally, 

Rarely. 

(B)    Podalic  Version 

I. 

2. 

3- 

External  Podalic. 

Combined  External  and  Internal 

Podalic  (Bipolar). 
Internal  Podahc. 

Rarely. 
Frequently. 

Most  frequently. 

(C)    Pelvic  Version 

( 

I. 

2. 

3- 

External  Pelvic. 

Combined  External  and  Internal 

Pelvic  (Bipolar). 
Internal  Pelvic. 

Rarely. 
Rarely. 

Obsolete. 

Introduction  of  the  Hand  in  Version. — The  hand  and  forearm,  being  thor- 
oughly aseptic,  are  enclosed  in  a  rubber  glove  and  well  lubricated  with  i  per 

cent,  lysol  or  creolin  solu- 
tion.    The   fingers    of   the 
hand  to  be  introduced  are 
then   brought   together   in 
the    form    of   a   cone,  and 
the  labia  separated  by  the 
thumb  and  first  and  second 
fingers    of    the  disengaged 
hand   (Fig.    1114).     (Com- 
pare vaginal  examinations, 
page    153.)     The    apex    of 
the    cone-shaped    hand    is 
then    pushed    into  the  os- 
tium vaginae,  and  entrance 
is     effected      by     pressing 
steadily  inward  and  back- 
ward   upon     the    distensi- 
ble perineum.     No  sudden 
movements  or  haste  should 
be  used,  and  ordinary  rota- 
tion and  boring-like  move- 
ments   of    the    hand     are 
unnecessary    and    increase 
the  tendency  to  laceration. 
Patience  and  lack  of  haste 
are  important  factors  for  success  and   avoidance  of  lacerations,  especially   in 
primiparous   patients.     After   the    hand    is    well    in   the   vagina  the   cervix   is 
sought,  and  in  combined  or  bipolar  version  one,  two,  or  three  fingers  are  care- 
fully inserted  through  the  os  according  to  circumstances.     In  internal  version 
the  hand  is  passed  through  the  os  in  practically  the  same  manner  as  through 
the  vulval  orifice,  but  in  all  cases  at  this  point  in  the  passage  of  the  hand  the 
fundus  should  be  steadied   and  even   pushed  down  with  the  external  hand  to 
avoid  dangerous  stretching  of  the  lower  uterine  segment,  or  too  great  traction 


Fig.  1 1 14. — Introduction  of  the  Hand  in  Internal 
Version.  Note  that  the  vulva  is  widely  separated  and 
that  the  entering  fingers  strongly  depress  the  perineum. 


VERSION. 


921 


of  the  uterine  attachments  by  the  upward  pressure  of  the  internal  hand. 
The  subsequent  use  of  the  fingers  in  combined  version,  and  of  the  hand  in 
internal  version  is  described  under  the  proper  sections. 


•4*. 


/ 


(A)   CEPHALIC  VERSION. 

Cephalic  version  is  not  applicable  to  cases  in  which  rapid  delivery  is  desired, 
nor  in  cases  of  decided  flattening  of  the  pelvis  unless  the  delivery  is  to  be  by 
symphyseotomy  and  forceps,  for  in  head-first  deliveries  in  flattened  pelves  we 
lose  the  decided  advantage  secured  by  breech  extraction  and  the  entrance  of  the 
head  into  the  pelvic  inlet  base  first.     Theoretically  cephalic  version  is  to  be  pre- 
ferred to  podalic  version  in 
all    but    a    few   exceptional 
cases,  because,  as  has  been 
stated  before,  the  prognosis 
for  the  fetus  is  always  better 
in  cases  in  which  it  passes 
head  first  through  the  pelvis 
than  in  either  spontaneous 
or  artificial  feet-first  labors. 
On  the  other  hand,  the  dex- 
terity on  the  part  of  the  oper- 
ator required  for  its  perform- 
ance, the  ease  with  which  po- 
dalic version  can  usually  be 
performed,  and  the  frequent 
necessity  for   rapid   extrac- 
tion after  version,  have  un- 
justly kept  cephalic  version 
in  the  background. 

Indications. — These  are 
very  limited,  principally  in 
shoulder  and  breech  presen- 
tation, but  not  when  rapid 
delivery  is  demanded,  and 
hence  the  method  is  unsuit- 
able in  placenta  praevia  and 
prolapse  of  the  cord 

I.  External  Cephalic  Ver- 
sion.— Indications :  Cephalic 
version  by  external  manipu- 
lation only  is  chiefly  applicable  to  cases  of  shoulder  presentation  or  oblique 
positions  of  the  fetus  in  the  uterus,  discovered  in  the  latter  part  of  pregnancy 
or  at  the  onset  of  labor.  Under  favorable  circumstances  it  may  also  be 
used  to  convert  a  pelvic  into  a  cephalic  presentation.  After  labor  has  com- 
menced this  method  may  be  used  if  sufiQcient  liquor  amnii  remains  and  the 
uterus  sufficiently  relaxes  between  the  pains.  Operation:  The  dorsal  posture  of 
the  patient  with  the  pillows  removed  is  to  be  preferred.  As  much  relaxation 
of  the  abdominal  muscles  as  possible  must  be  secured  by  flexing  the  thighs. 
Anesthesia  usually  is  not  necessary,  but  in  nervous  patients  may  be  required, 
and  employed  to  advantage.    For  success  it  is  necessary  to  make  out  with  certainty 


Fig.  1 1 15. — External  Cephalic  Version  in  Breech 
Presentation.  Note  that  the  fetus  is  made  to  travel 
occiput  first  about  the  uterine  cavity. 


922 


OBSTETRIC  SURGERY. 


the  existing  position  and  presentation  of  the  fetus,  this  being  done  by  both 
external  and  internal  palpation.     Before  the  operation  is  begun  a  clear  mental 
picture  should  also  be  formed  of  just  what  is  to  be  done.     In  shoulder  presenta- 
tions and  oblique  positions  of  the  fetus  it  is  always  desirable  to  have  the  head 
take  the  shortest  road  to  the  pelvic  inlet,  and  in  pelvic  presentations  we  should 
aim  to  have  the  fetus  revolve  occiput  first  about  the  pelvis  in  order  to  avoid 
unnecessary  extension  of  the  head,  provided  this  can  readily  be  accomplished. 
With  the  palm  of  one  hand  upon   the   breech  and  the  other  upon  the  head 
the  breech  is  carefully  pushed  up,  the  head  down,  until  the  long  axis  of  the 
fetus  corresponds  to  that  of  the  uterus  and  the  head  lies  over  the  pelvic  inlet 
(Figs.  II 15  and  11 16).     Revolution  of  the  fetus  is  often  readily  performed,  especi- 
ally in  shoulder  presentations,  but,  the  cause  of  the  malpresentation  existing,  re- 
turn of  the  fetus  to  its  orig- 
inal presentation  often  oc- 
curs;   this    I    have    found 
especially  true  of  pelvic  pre- 
sentations.    In  such  cases 
I  have  found  a  pad  on  each 
side  of  the  uterus   to  hold 
the  fetus  in  place  of  little 
use   before    labor  actually 
sets  in,  but  the  case  should 
be  carefully  watched  and 
reposition  again  performed 
at  the  onset  of  labor  and 
the  fetus  held  in  position 
until    engagement    occurs. 
In  private  practice  I  once 
thus    changed    a    shoulder 
into  a  vertex'  presentation 
in  the  beginning  of  the  first 
stage  and  held  the  head  at 
the  pelvic  inlet  by  grasping 
it  with  one  hand  externally 
for    three   hours,    when  it 
finally  engaged.  No  further 
anomaly  occurred  and  the 
patient  and  fetus  were  thus 
saved  from  the  dangers  of 
a  podalic  version.     In  gen- 
eral, after  correction  of  the 
malpresentation  it  is  advisable  to  keep  the  patient  quiet  in  bed  in  the  dorsal 
posture  so  that  the  fundus  uteri  shall  not  incline  to  one  side  or  the  other  until 
the  desired  presentation  is  effected.     Fixation  of  the  head  in  the  pelvic  inlet  mav 
be  hastened  and  promoted  by  artificially  rupturing  the  membranes,  as  soon  as  the 
dilatation  of  the  os  warrants  it. 

II.  Combined  or  Bipolar  Cephalic  Version. — Various  methods  of  performing 
version  by  one  hand  passed  into  the  vagina,  one  or  more  fingers  of  which  being 
passed  through  the  os,  and  the  other  hand  upon  the  anterior  abdominal  wall, 
have  been  described  by  Busch,  Hohl,  Wright  of  Cincinnati,  and  Braxton  Hicks 
of  England.*     The  method  as  now  usually  practised  is  according  to  the  principles 

*  Hicks:  "  Combined  External  and  Internal  Version,"  1864. 


Fig. 


1 1 16. — External  Cephalic  Version  in  Shoulder 
Presentation. 


VERSION.  923 

laid  down  by  Braxton  Hicks,  although  priority  has  been  claimed  for  Wright, 
of  Cincinnati.*  Posture  of  the  patient:  Usually  the  dorsal  posture  is  more  con- 
venient for  both  operator  and  patient.  Hicks  advises  a  choice  of  lateral  position 
to  assist  by  gravity  the  performance  of  the  operation.  Thus,  in  shoulder  pres- 
entation with  the  fetal  head  to  the  patient's  left  side,  and  the  breech  therefore 
toward  the  right.  Hicks  advises  the  left  lateral  posture  of  the  patient,  so  that 
the  effect  of  gravity  upon  the  fundus  will  assist  in  the  operation  by  carrying 
the  breech  to  the  left  and  the  head  thus  over  the  pelvic  inlet.  The  reverse 
may  be  tried  when  the  fetal  head  is  to  the  mother's  right.  As  in  other  varieties 
of  version,  so  here,  the  knee-chest  posture  of  the  patient  has  been  recommended 
and  used  to  assist  in  the  recession  of  a  partially  fixed  shoulder  or  breech.  This 
posture  I  have  found  difficult  for  the  patient  to  keep  for  any  time,  and  not 
more  efficient  than  the  exaggerated  left  latero-prone  posture,  which  any  patient 
can  easily  assume  (Fig.  1051).  The  right  and  left  exaggerated  latero-prone 
posture  can  be  used  as  directed.  For  ordinary  cases  the  dorsal  posture  will  be 
found  the  most  convenient. 

In  Shoulder  Presentation. — It  is  in  this  presentation  more  than  in  pelvic 
that  combined  cephalic  version  is  used.  The  term  "bipolar"  cannot,  strictly 
speaking,  be  applied  to  combined  cephalic  version  in  shoulder  presentation  until 
the  latter  part  of  the  procedure,  when  both  poles  of  the  fetal  ellipse  are  grasped. 
Anesthesia  is  not  always  necessary  but  usually  desirable,  and  it  certainly  facili- 
tates the  operation.  As  in  all  varieties  of  version,  a  certain  diagnosis  of  the 
exact  position  of  the  fetus  is  necessary  for  success.  The  operator  should  use 
for  the  internal  hand  the  one  the  palm  of  which  would  naturally  face  the 
fetal  breech,  or  the  hand  the  fingers  of  which  naturally  flex  toward  the 
fetal  breech.  Thus  in  right  scapula  positions  of  the  shoulder  he  should 
use  the  left  hand  internally,  and  in  left  scapula  positions  the  right  hand 
in  the  vagina.  If  possible,  he  passes  two  fingers  through  the  os,  as  thus 
more  force  can  be  secured  and  there  is  less  danger  of  rupturing  the  mem- 
branes with  two  than  with  one  finger.  With  the  external  hand  steadying  the 
head,  the  two  fingers  in  the  lower  uterine  segment  by  a  movement  of  flexion 
push  the  apex  of  the  shoulder  upward  and  toward  the  side  of  the  uterus  occupied 
by  the  breech;  at  the  same  time  the  external  hand,  already  placed  upon  the 
head,  pushes  the  head  down  into  the  pelvic  inlet,  where  it  is  recognized  and 
received  by  the  two  internal  flngers  and  further  adjusted  to  the  inlet.  For  the 
version  to  be  completed  the  long  axis  of  the  fetus  must  correspond  to  that 
of  the  uterus.  In  some  instances  the  fetal  breech  will  not  readily  rotate  into 
the  fundus  even  after  the  head  occupies  the  pelvic  inlet.  In  such  cases  it  is 
advisable  to  withdraw  the  vaginal  hand,  the  external  hand  still  firmly  holding 
the  head  at  the  inlet,  and  to  use  this  hand  to  push  up  the  breech  into  the  fundus. 
It  is  only  at  this  point  in  the  operation  that  the  operation,  strictly  speaking, 
is  "bipolar,"  namely,  the  forces  are  applied  to  the  opposite  poles  of  the 
fetal  ellipse.  The  head  must  be  held  by  external  palpation  until  it  engages 
or  until  engagement  can  be  hastened  by  artificial  rupture  of  the  membranes. 

In  Breech  Presentation. — It  is  often  desirable  at  the  onset  of  labor  to  convert 
a  breech  into  a  vertex  presentation  in  order  to  better  the  prognosis  for  both  fetus 
and  mother.  External  version  should  always  be  tried  first,  and,  failing  in  this, 
we  resort  to  combined  external  and  internal  version.  Under  such  circumstances 
the  version  is,  strictly  speaking,  "bipolar,"  since  force  is  applied  to  both  poles 
of  the  fetal  ellipse.  Operation:  The  same  general  principles  as  to  preparation 
and  posture  of  the  patient  apply  here  as  in  cephalic  version  in  shoulder  presenta- 

*  "  Amer.  Jour,  of  Obstet.,"  vol   vi,  Part  I,  1S73. 


924 


OBSTETRIC  SURGERY. 


tion.  As  in  shoulder  presentation,  so  here,  there  is  a  distinct  advantage  to 
the  operator  and  the  prognosis  in  the  choice  of  the  hand  to  be  used  internally. 
The  principle  to  be  followed  here  as  in  other  varieties  of  version  is  to  have 
the  fetal  ellipse  revolve  "  occiput  first  "  about  the  uterine  cavity.  Of  course,  it 
is  just  as  short  a  distance  for  the  head  to  revolve  one  way  as  the  other  in  pelvic 
presentation.  So  in  left  sacro  positions  of  the  breech  it  is  advantageous  to 
use  two  fingers  of  the  right  hand  in  the  lower  uterine  segment,  by  flexing 
these  fingers  to  push  the  fetal  breech  to  the  mother's  right,  and  thus  the 
occiput  will  traverse  the  left  wall  of  the  uterus  and  there  will  be  little  danger 
of  head  extension  or  prolapse  of  the  hands  or  arms.  In  left  sacro  positions  the 
left  hand  is  used  externally  to  push  the  head  around  the  left  wall  of  the  uterus 
in  conjunction  with  the  efforts  of  the  internal  right  hand.  As  soon  as  the  breech 
has  disappeared  from  the  touch  of  the  internal  fingers  these  remain  quiescent 
until  the  apex  of  the  shoulder  can  be  reached,  when  it  is  pushed  by  a  movement 
of  flexion  with  the  fingers  in  the  direction  the  breech  has  taken.  After  the  shoulder 

has  been  passed  on,  the  internal  fin- 
gers at  the  OS  await  the  coming  of  the 
head,  as  in  combined  cephalic  version 
1  \  in  shoulder  presenfation.     If  after  the 

bringing  down  of  the  head  it  is  found 
that  the  fetal  breech  has  not  ascended 
so  far  as  the  fundus,  the  vaginal  hand 
is  withdrawn  and  used  to  push  up  the 
breech,  the  head  being  still  held  in 
place  with  the  original  external  hand, 
[n  right  sacro  positions  the  choice  of 
hands  is  reversed,  as  the  left  hand  is 
used  inte'mally  and  the  right  extern- 
ally. 

III.  Internal  Cephalic  Version. — 
Before  the  introduction  of  internal 
podalic  version  internal  cephalic  ver- 
sion was  frequently  performed  by 
passing  the  whole  hand  into  the 
uterus,  grasping  the  fetal  head,  and 
drawing  it  down  into  the  os.  The 
operation  is  more  difficult  than  com- 
bined or  internal  podalic  version  and  the  maternal  prognosis  is  not  so  good, 
although  theoretically  the  fetal  prognosis  is  better.  After  the  introduction  of 
podalic  version  the  cephalic  variety  was  practically  abandoned,  but  has  recently 
been  revived.  Conditions  necessary:  Complete  dilatation  of  the  os  with  no  dis- 
proportion between  the  head  and  maternal  parts.  The  operation  is  not  intended 
for  rapid  delivery.  Operation — method  of  D'Outrepont:  The  uterus  is  supported 
with  the  external  hand.  The  internal  hand  seizes  the  presenting  shoulder  and, 
during  the  intervals  between  the  pains,  pushes  the  shoulder  upward  and  in  the 
direction  of  the  breech,  until  the  head  descends  into  the  pelvic  inlet  (Fig.  my). 
Method  of  Busch:  The  head,  if  on  the  left  side,  is  grasped  by  the  right  hand  through 
the  cervix  while  the  other  hand  carries  up  the  breech ;  the  head  is  then  drawn 
as  far  as  possible  into  the  cervix  by  the  operator's  hand,  with  the  thumb  and 
little  finger  upon  the  temples  and  the  other  three  fingers  over  the  occiput  (Fig. 
in  8).  Vienna  method:  By  the  Vienna  method  the  head  is  guided  to  a  position 
over  the  os  by  the  combined  method  of  Hohl  {q.  v.)  and  then  grasped  and 
drawn  into  the  cervix. 


Fig.     my. — Internal    Cephalic    Version. 
D'Outrepont's  Method. 


VERSION. 


925 


;'/: 


/ 


(B)  PODALIC  VERSION. 

Combined  and  internal  podalic  versions  are  performed  more  frequently  than 
all  other  varieties,  so  much  so  that  in  America  the  general  term  version  is  almost 
synonymous  with  internal  podalic  version. 

Indications. — Podalic  version  is  indicated;  (i)  in  shoulder  presentation  when 
cephalic  version  has  failed  or  the  conditions  are  unfavorable  for  its  performance; 
(2)  in  cephalic  presentation  when  the  prognosis  is  bettered  by  feet-first  delivery, 
as  in  contracted  pelves ;  prolapse  of  the  cord  or  extremities ;  in  certain  malpresen- 
tations  and  malpositions,  such  as  face  and  brow  presentations,  and  in  persistent 
occipito-  and  mento-posterior  positions  at  the  pelvic  inlet ;  (3)  in  certain  emergen- 
cies either  for  the  control  of  hemorrhage  or  for  rapid  delivery,  such  as  placenta 
praevia  and  accidental  hemor- 
rhage, eclampsia,  or  sudden 
death  of  the  mother. 

I.  External  podalic  version  is 
never  used,  the  combined  or  bi- 
polar and  the  internal  methods 
being  preferred. 

II.  Combined  or  Bipolar  Po- 
dalic Version. — The  method  used 
to-day  is  practically  the  bipolar 
method  of  internal  and  external 
manipulation  of  Braxton  Hicks. 
I  shall  not  enter  into  a  compari- 
son of  the  difference  in  the  com- 
bined methods  of  Busch,*  D'Ou- 
trepont,t  Wright, J  Hohl,§  and 
Hicks, II  since  they  differ  merely 
in  detail,  all  simultaneously  em- 
ploying the  external  and  internal 
hand,  but  discuss  only  Hohl's 
and  Hicks 's  methods,  which  limit 
the  internal  hand  to  the  intro- 
duction of  one  or  two  fingers 
through  the  os.     The  methods 

of  Busch  and  D'Outrepont,  which  required  the  introduction  of  the  whole  hand 
through  the  cervix,  are  to-day  practically  obsolete.  Any  method  of  combined 
podalic  version  which  necessitates  the  introduction  of  the  whole  hand  into 
the  uterus  can  scarcely  give  better  results  than  internal  podalic  version.  The 
priceless  advantage  of  the  method  described  by  Hicks  is  that  it  can  be  per- 
formed early  in  labor,  or  even  in  late  pregnancy,  as  its  only  requisites  for 
success  are  (i)  sufficient  mobility  of  the  fetus  in  the  uterus;  (2)  an  exact 
diagnosis  of  the  fetal  presentations  and  position;  and  (3)  sufficient  dilatation 
of  the  OS  to  allow  of  the  passage  of  two  fingers. 

I.  In  Shoulder  Presentation. — Bipolar  podalic  version  may  be  tried  in 
cases  in  which  external  or  combined  cephalic  have  failed,  or  in  cases  of  shoulder 

*Scanzoni:  "  Lehrbuch  der  Geburtshiilfe,"  1S69,  Bd.  iii,  p.  63.  t  Op.  cit.,  p.  65. 

t  Wright:   "  Amer.  Jour.  Obstet.,"  vol.  vi,  Part  I,  1873. 
§  Hohl:   "  Lehrbuch  der  Geburtshiilfe, "  Auflage  1S62,  p.  7S4. 

II  Hicks:  "Combined  External  and  Internal  Version,"  "Trans.  London  Obstet.  Soc  ." 
vol.  V,  p.  230;   "Amer.  Jour.  Obstet.,"  July,  1S79,  p.  593 


V 

/ 


Fig.      1118. 


Internal      Cephalic 
Busch's  Method. 


Version. 


926 


OBSTETRIC  SURGERY. 


presentations  in  which  it  is  very  important  to  bring  down  a  leg  to  control 
hemorrhage,  as  in  placenta  praevia,  or  for  purposes  of  subsequent  rapid  delivery. 
In  all  such  cases  in  which  the  naembranes  are  intact,  or  in  which  they  have  not 
long  been  ruptured,  bipolar  podalic  version  can" be  attempted  without  any  disad- 
vantage or  danger  to  mother  or  fetus ;  for  should  circumstances  prevent  recession 
of  the  shoulder,  and  version  by  this  method  fail,  the  hand  can  be  passed  into 
the  uterus,  provided  there  is  sufficient  dilatation,  and  internal  podalic  version 
promptly  performed.     Operation:  Anesthesia  as  in  combined  cephalic  version  is 


'(^■^. 


Fig.  1 1 19. — -Combined  or  Bipolar  Po- 
dalic Version.  Braxton  Hicks's 
Method.     First  Step. 


Fig.  1120. — Combined  or  Bipolar  Podalic  Ver- 
sion. Braxton  Hicks's  Method.  Second 
Step. 


a  practical  necessity.  The  dorsal  posture  of  the  patient  upon  a  sufficiently 
high  table  is  usually  to  be  preferred,  although  the  lateral  or  exaggerated  semi- 
prone  can  be  substituted  in  difficult  cases.  (See  page  872.)  The  internal  hand 
should  be  the  one  whose  fingers  naturally  flex  toward  the  fetal  head;  thus,  in  left 
scapula  positions  the  left  hand  is  used  internally,  and  in  right  scapula  positions 
the  right  hand.  The  proper  hand  is  introduced  into  the  vagina  and  two  fingers 
are  passed  through  the  os.  The  external  hand  rests  over  the  fetal  breech. 
Now  with  the  internal  fingers  the  presenting  shoulder  is  gently  pushed  upward  in 
the  direction  of  the  head  and  at  the  same  time  somewhat  toward  the  fundus.    This 


VERSION. 


927 


latter  movement  brings  the  fetal  abdomen  in  part  over  the  os,  and  renders 
descent  and  grasping  of  a  foot  more  easy.  At  the  same  time,  with  the  external 
hand  the  breech  is  pushed  down  into  the  lower  uterine  segment  to  replace  the 
shoulder.  If  this  substitution  can  be  accomplished,  the  most  available  knee  or 
foot,  which  is  usually  the  anterior,  is  sought  for  by  the  internal  fingers  and  hooked 
down  into  the  vagina  through  the  os.  When  once  the  knee  or  foot  is  caught, 
the  external  hand  is  transferred  from  the  breech,  which  it  has  been  pushing  down, 
to  the  lower  portion  of  the  fetal  head,  which  it  pushes  upward  and  into  the  fundus 
uteri.  The  ease  with  which  the  operation  is  performed  will  depend,  of  course, 
upon  the  mobility  of  the  fetus  in  the  uterus,  and  practically  upon  the  amount  of 
liquor  amnii.  It  is  generally  considered  that  prolapse  of  an  arm  renders  the  per- 
formance of  combined  podalic  ver- 
sion in  shoulder  presentation  im- 
possible. Dr.  Frank  P.  Foster,  of 
New  York,*  operated  in  such  a 
case  by  using  the  prolapsed  arm 
as  an  aid  to  the  version.     Thepre- 


FlG.       1 12 1. ^COMBINED      OR       BiPOLAR       PoDALIC 

Version.     Braxton  Hicks's  Method.    Third 
Step. 


Fig.  II22. — Half  Breech  Formed 
WHEN  One  Leg  is  Brought  down 
IN  Podalic  Version. — (Leopold.) 


sentation  was  a  shoulder  and  the  position  right  scapula  anterior  with  the  left  arm 
prolapsed  into  the  vagina.  With  the  right  hand  in  the  vagina  Dr.  Foster  grasped 
the  arm,  and,  using  it  as  a  kind  of  handle,  gently  pushed  upward  in  the  direction 
of  the  humerus.  The  shoulder  and  cephalic  pole  of  the  fetus  were  thus  elevated, 
and  with  the  index- finger  in  the  cervix  the  breech  was  reached  and  pushed  in  the 
direction  the  head  had  taken  until  the  leg  was  recognized  and  brought  down. 

2.  In  Cephalic  Presentations. — (Figs.  iii9toii22.)  The  indications  and 
conditions  necessary  for  the  performance  of  bipolar  podalic  version  in  cephalic 
presentation — namely,  vertex,  brow,  and  face — are  practically  the  same  as  in 

*  Foster:  "  On  Prolapse  of  the  Arm  in  Transverse  Presentations,"  "  Amer.  Jour,  of 
Obstet.,"  vol.  IX,  p.  203. 


928  OBSTETRIC  SURGERY. 

shoulder  presentation.  The  head  must  not  be  too  firmly  engaged.  Operation: 
Anesthesia  here  is  also  a  necessity  and  the  dorsal  posture  is  to  be  preferred  in 
ordinary  cases.  As  in  shoulder  presentation,  a  movable  fetus  and  an  exact  diag- 
nosis of  the  presentation  and  position  are  necessary  for  success.  It  is  important 
that  the  fetus  shall  revolve  occiput  first  about  the  uterus.  This  causes  the  feet 
to  travel  about  the  shortest  possible  distance  in  order  to  reach  the  cervix;  there 
is  less  danger  of  extended  head  and  arms,  and  the  revolution  of  the  fetus  thus  is 
more  readily  accomplished.  Hence,  contrary  to  many  authorities,  I  believe  that 
there  is  a  distinct  choice  in  the  hand  used  internally.  In  left  dorso  positions  the 
left  hand  should  be  used  internally,  and  in  right  dorso  positions  the  right  hand, 
(i)  With  the  appropriate  hand  in  the  vagina,  two  fingers  through  the  os,  and  the 
external  hand  on  the  breech,  the  internal  fingers  by  a  movement  of  flexion  gently 
push  the  head  upward  and  in  the  direction  of  the  occiput,  the  external  hand  at 
the  same  time  pushing  the  breech  b}''  a  gentle  sliding  motion  in  the  opposite  direc- 
tion. This  is  to  be  continued  until  the  head  has  passed  out  of  the  reach  of  the 
internal  fingers.  (2)  As  the  head  departs  from  the  internal  fingers,  if  all  goes 
well,  the  normal  attitude  of  the  fetus  is  preserved  and  no  extension  of  the  head 
or  displacement  of  the  arms  occurs.  The  external  hand  now  simply  continues  its 
pressure  and  forces  the  breech  with  the  feet  into  the  lower  uterine  segment,  where 
one  of  the  latter  or  a  knee  is  secured  by  the  fingers  of  the  internal  hand.  In  less 
favorable  cases,  by  reason  of  the  uterus  enveloping  the  fetus  too  closely,  extension 
of  the  head  takes  place ;  it  does  not  readily  pass  upward  along  the  side  of  the  uterus 
into  the  fundus,  and  the  shoulder  or  fetal  chest  is  felt  by  the  internal  fingers  just 
over  the  os.  In  such  cases  one  must  treat  the  shoulder  or  chest  in  the  same  way 
as  the  head  by  gently  pushing  it  upward  in  the  same  direction  the  head  has  taken. 
Care  should  be  used  in  this  case  not  to  confound  an  elbow  with  a  knee.  (See 
page  931.)  As  soon  as  a  knee  or  a  foot  is  recognized  it  should  be  seized,  and 
the  membranes  be  ruptured  if  still  intact.  (3)  After  the  knee  or  foot  is  firmly 
secured  by  the  internal  fingers,  the  external  hand  is  transferred  from  the  breech  to 
the  other  side  of  the  abdomen  and  placed  below  the  head,  which-is  by  a  gentle 
sliding  motion  pushed  upward  into  the  fundus,  while  at  the  same  time  the  foot  is 
drawn  down  through  the  os  into  the  vagina.  Some  operators  always  bring  down 
a  knee  through  the  os  and  afterward  extend  the  leg  in  the  vagina,  claiming  that 
a  better  grasp  is  to  be  had  in  the  flexure  of  the  knee  than  on  the  foot.  I  have 
found  it  much  more  convenient  and  simple  to  seize  the  foot  in  the  uterus,  as  it  will 
be  found  that  the  foot  comes  first  within  reach  of  the  internal  fingers.  The  leg 
being  through  the  os,  traction  should  be  made  upon  it  until  two-thirds  of  the  thigh 
has  passed  through  the  os  and  the  half  breech  is  beginning  to  enter.  This  will  bring 
the  foot  outside  the  vulva.  As  traction  is  thus  being  made  upon  the  leg,  external 
palpation  is  used  to  make  sure  that  the  head  occupies  the  fundus.  Traction  on 
the  leg  until  the  thigh  engages  in  the  os,  combined  with  external  upward  pressure 
on  the  head,  assists  in  completing  the  version  and  preventing  recession  of  the  part 
engaged.  When  the  long  axis  of  the  fetus  corresponds  to  that  of  the  uterus  the 
version  is  completed.  Whatever  is  subsequently  done  in  the  way  of  extraction 
will  be  quite  another  operation.  Choice  of  the  leg  to  he  seized:  It  is  generally 
stated  that  in  combined  podalic  version  in  head  presentations  there  is  no 
choice  as  to  which  leg  is  seized  and  that  it  makes  no  difference  whether  it  is 
the  anterior  or  posterior  which  is  secured.  There  is  a  principle  in  all  varie- 
ties of  internal  version,  namely,  that  the  leg  which  is  brought  down  always 
eventually  rotates  forward  behind  the  symphysis.  This  rule  has  few  exceptions. 
Hence  it  will  be  found  expedient,  in  order  to  avoid  unnecessary  rotation  of  the 
fetus  within  the  uterus,  always  to  attempt  at  least  to  seize  the  anterior  knee  or 


< 


VERSION.  929 

foot,  unless  some  distinct  indication  to  the  contrary  exists.  There  is  practically 
but  one  exception  to  the  rule  of  seizing  the  anterior  foot,  and  that  exception  exists 
in  flattened  pelves  after  it  has  been  definitely  determined  that  more  room  exists  on 
one  side  of  the  pelvis  than  the  other  on  account  of  the  greater  width  of  the  sacral 
ala  on  one  side.  In  such  a  contingency  it  is  desirable  to  bring  the  occiput  and  the 
wide  biparietal  diameter  into  the  roomiest  lateral  half  of  the  pelvis.  Since,  as 
stated  above,  the  leg  which  is  brought  down  always  eventually  rotates  to  the 
symphysis,  if  we  desire  the  occiput  to  occupy  a  roomy  left  side  of  the  pelvis  we 
bring  down  the  left  foot,  and  the  right  if  we  want  the  occiput  in  the  right  half. 
Fig.  882  (page  650)  illustrates  the  type  of  pelvis  referred  to,  in  which,  as  will  be 
seen,  the  roomiest  lateral  half  of  the  pelvis  is  the  left  half.  It  is  not  by  any  means 
always  possible  to  choose  a  given  knee  or  foot  with  two  or  three  fingers  only  in 
the  lower  uterine  segment,  hence  in  cases  in  which  the  choice  of  the  leg  to  be 
seized  is  important  in  the  prognosis,  it  is  better  to  wait  until  spontaneous  or 
artificial  dilatation  is  accomplished,  to  pass  the  whole  hand  into  the  uterus  and  to 
select  the  desired  leg,  thus  practically  doing  an  internal  podalic  version.  (Com- 
pare page  933.) 

III.  Internal  Podalic  Version. — This  is  one  of  the  most  valuable  resources  in 
obstetric  emergencies.  It  is  indicated  when  the  safety  of  the  mother  or  child 
requires  immediate  delivery,  and  when  the  use  of  the  forceps  is  contraindicated 
(e.  g.,  in  placenta  prasvia,  puerperal  eclampsia,  prolapse  of  the  cord,  etc.).  It 
is  also  indicated  in  various  malpositions  in  which  natural  delivery  or  deliver}' 
by  forceps  is  hazardous  or  impossible  {e.  g.,  in  delayed  first  stage  due  to  occipito- 
posterior  position,  or  to  face  presentation),  and  in  cases  in  which  the  after- 
coming  head  is  better  adapted  than  the  fore-coming  head  to  pass  through  the 
birth  canal  (e.  g.,  in  flattened  pelvis).  Internal  podalic  version  in  both  cephalic 
and  shoulder  presentation  is  to-day  performed  so  frequently  that  when  the  term 
version  is  used  it  is  often,  if  not  always,  understood  to  mean  internal  version. 
Operation :  The  operation  consists  in  the  introduction  of  the  whole  hand  into 
the  uterus,  seizing  a  foot  or  two  feet,  bringing  it  or  them  into  the  vagina  through 
the  OS,  and  pushing  the  fetal  head  into  the  fundus  by  external  manipulation 
with  the  external  hand.  Unfortunately  the  version  by  the  internal  method  is 
most  easy  of  performance,  hence  it  is  often  done  without  first  giving  ex- 
ternal or  combined  version  a  trial.  It  should  ever  be  borne  in  mind  that  the 
operation  of  internal  podalic  version,  whether  in  shoulder  or  cephalic  presenta- 
tion, is  a  serious  operation  and  one  not  lightly  to  be  undertaken;  that  there  are 
always  distinct  dangers  of  injury  to  the  maternal  soft  parts,  even  to  the  extent  of 
rupture  of  the  uterus;  that  the  danger  of  the  introduction  of  septic  material  and 
air  into  the  uterus  and  to  the  placental  site  is  ever  present;  that  podalic  version 
once  completed  means  the  delivery  of  the  fetus  spontaneously  or,  as  usually 
occurs,  artificially  feet  first,  and  that  in  such  delivery  the  mortality  is  always 
greater  for  the  fetus,  and  the  morbidity  for  the  mother,  than  in  most  cases  of 
spontaneous  or  artificial  head-first  deliveries.  The  fetus  was  intended  by  nature 
to  pass  head  first  through  the  pelvis.  Reverse  nature's  process  and  the  breech, 
a  poorer  dilator  than  the  head,  is  the  first  to  pass  through  and  dilate  the  passages ; 
then  come  the  dangers  of  arms  extended  over  and  impacting  the  head;  extension 
of  the  head  increasing  the  danger,  and  the  delivery  of  the  incompressible  head 
rapidly,  in  ten  minutes  at  most,  through  passages  imperfectly  dilated  by  the  fore- 
coming  breech. 

Conditions  Necessary  and  Contraindications . — Pelvic  deformity  must  not 
be  too  great,  nor  must  it  be  of  such  a  kind  as  to  interfere  with  the  passage  of 
the  after-coming  head.  The  cervix  must  be  completely  dilated.  If  this  is  not 
59 


930 


OBSTETRIC  SURGERY. 


the  case,  complete  manual  dilatation  and  paralysis  should  be  secured  as  a  pre- 
requisite. In  rare  cases  incision  may  be  necessary.  There  must  not  be  tetanic 
contraction  of  the  uterus,  and  it  is  highly  desirable  that  the  membranes  should 
not  be  ruptured  or  should  only  recently  have  ruptured.  The  presence  of  the 
contraction  ring  above  the  fetal  head  or  more  than  four  inches  above  the  sym- 
physis renders  the  operation  extremely  hazardous,  owing  to  the  danger  of 
uterine  rupture.  If  the  head  is  impacted  or  firmly  wedged  in  the  pelvic  inlet, 
so  that  much  pressure  is  required  to  dislodge  it,  version  is  of  course  contra- 
indicated.  Version  should  not  be  performed  for  the  delivery  of  a  very  small 
or  of  a  premature  child,  unless  the  forceps  is  contraindicated,  for  forceps 
delivery  in  these  cases  is  usually  easy,  and  if  properly  performed  less  likely  to  be 


■•^ 


\ 


Fig.  1123. — Internal  Podalic  Version 
IN  Cephalic  Presentation.  Intro- 
duction of  the  internal  hand  into  the 
uterus,  and  downward  pressure  of  the 
external  hand  to  bring  the  legs  within 
reach  of  the  internal  hand. 


Fig.  1 124. — Internal  Podalic  Version  in 
Cephalic  Presentation.  Grasping  the 
anterior  leg  with  the  internal  hand  and 
upward  pressure  upon  the  anterior  shoulder 
with  the  external  hand. 


fatal  to  the  child.  Internal  version  should  not  be  performed  for  the  delivery 
of  a  macerated  or  dead  fetus.  If  the  child  is  dead,  craniotomy  should  be  per- 
formed unless  the  delivery  promises  to  be  very  easy  and  unattended  by  lacera- 
tion of  the  maternal  structures. 

General  Preparations. — The  dorsal  posture  of  the  patient  upon  a  high  oper- 
ating table  is  to  be  preferred  to  the  lateral,  exaggerated  semi-prone,  knee-chest, 
and  Trendelenburg  postures,  in  all  but  exceptional  cases.  In  difficult  versions  in 
impacted  shoulder  presentation  the  Trendelenburg  and  exaggerated  semi-prone 
position  will  greatly  assist  our  endeavors  to  dislodge  the  impacted  shoulder.  (See 
page  879.)  The  bladder  and  rectum  must  be  thoroughly  emptied,  the  pubic  hair 
removed,  and  I  am  accustomed  to  prepare  the  external  genitals,  adjacent  parts, 


VERSION. 


931 


and  vagina,  as  for  a  major  gynecological  procedure;  vaginal  hysterectomy,  for 
example.  Of  course,  vaginal  mucus  and  lubrication  are  thus  removed,  but  it  will 
be  found  that  a  good  substitute  is  a  i  per  cent,  solution  of  lysol,  with  which  the 
vagina  should  finally  be  freely  irrigated.  Anesthesia  is  a  necessity  in  internal  ver- 
sion, as  it  is  important  for  the  maternal  and  fetal  prognosis  that  the  greatest  pos- 
sible relaxation  of  the  uterus  be  obtained.  Theoretically,  chloroform  gives  a  more 
thorough  uterine  relaxation  than  ether,  but  it  will  be  found  that  ether,  if  properly 
given,  will  answer  every  purpose,  and  it  is  certainly  the  safer  anesthetic.  (Com- 
pare Anesthesia,  page  865.) 

r.   In  Vertex,  Bregma,  Brow,  and  Face  Presentations. — The  prepara- 


\ 


Fig.  1 125. — Internal  Podalic  Version  in 
Left  Scapulo-posterior  Position  of  the 
Shoulder.  The  right  hand  is  used  inter- 
nally to  grasp  the  feet,  and  the  left  ex- 
ternally to  depress  the  fundus.  This  method 
is  not  recommended. 


Fig.  1126. — Internal  Podalic  Version 
IN  Left  Scapulo-posterior  Position 
OF  THE  Shoulder.  The  left  hand,  the 
palm  of  which  naturally  faces  the  fetal 
abdomen,  is  used  internally  to  grasp  the 
feet,  and  the  right  hand  externally  to 
depress  the  fundus.  This  method  is  to 
be  preferred  to  that  of  Fig.  1125. 


tions  having  been  carefully  made,  here,  as  in  other  varieties  of  version,  success 
depends  upon  an  accurate  diagnosis  of  the  presentation  and  position.  Our 
object  in  internal  podalic  version  in  cephalic  presentations  is  to  pass  the  whole 
hand  into  the  uterus,  seize  one  or  two  feet,  bring  the  latter  into  the  vagina, 
and  assist  the  head  with  the  external  hand  to  pass  upward  and  occupy  the 
fundus  of  the  uterus. 

Choice  of  Internal  Hand. — According  to  many  authorities,  the  primary 
choice  of  hands  is  not  a  matter  of  great  consequence.  I  believe,  however,  the 
choice  of  hands  to  be  an  important  factor  in  the  prognosis;  and  the  greater 
the  operator's  experience,  the  greater  care  will  he  exercise  in  this  respect.     That 


932 


OBSTETRIC  SURGERY. 


hand  should  be  used  internally  the  palm  of  which  naturally  without  exaggerated 
pronation  or  supination  faces  the  fetal  abdomen.     Thus,  in  left  dorso  positions 
— namely,  left  occipito-anterior  and  -posterior,  right  mento-anterior  and  -poste- 
rior, and  right  fronto-anterior  and  -posterior — the  left  hand  is  the  one  to  use  in- 
ternally for  grasping  the  foot  or  feet,  as  this  hand  most  naturally  by  the  shortest 
path  and  with  least  disturbance  of  the  fetal  ellipse  comes  to  the  feet  and  readily 
selects  one  or  both  for  traction.     However,  in  right  dorso  positions — namely,  in 
right  occipito-anterior  and  -posterior,  in  left  mento-anterior  and  -posterior,  and 
in  left  fronto-anterior  and  -posterior — the  right 
hand  should  be  used,  for  the  above  reasons. 
In  pelves  flattened  from  any  cause,  and  especi- 
ally if  the  pelvic  inclination  is  increased,  there 
may   be   a   decided   posterior   obliquity  of   the 
uterine  axis  in  reference  to  the  axis  of  the  pelvic 
inlet,  with  a  perfectly  movable  head.  Under  such 
circumstances  rotation  of  the  fetal  back  often 
occurs  and  the  feet  are  found  not  to  one  side,  but 
well  up  against  the  posterior  wall  of  the  fundus. 

Here,  of  course,  it.  is  immaterial  which  hand  is  ><j^    \       ;r 

used  internally,  but  in  the  great  majority  of  cases  ;/\     ]       y 


Fig.    1127. — Method  of  Grasping  One  Foot. 


Fig.  1 12S. ^Method  of  Passing 
A  Sling  over  a  Foot  Pro- 
lapsed INTO  the  Cervix  or 
Vagina. 


of  cephalic  presentation  external  and  internal  examination  will  reveal  the  fetal 
dorsum  inclined  either  to  the  left  or  right. 

Treatment  of  Intact  Membranes. — If  internal  version  is  to  be  performed  when 
the  membranes  are  intact,  and  it  is  most  desirable  and  advantageous  that  they 
shall  remain  unruptured  until  the  hand  is  introduced  into  the  vagina,  and  the 
liquor  amnii  thus  being  dammed  back  in  the  uterus  after  the  membranes  are  finally 
artificially  ruptured,  the  question  is  often  asked.  What  is  the  treatment  of  the  un- 
ruptured membranes?  Three  plans  have  been  practised  by  various  authorities  in 
time  gone  by :  ( i )  One  plan  is  to  seize  the  foot  or  feet  through  the  unruptured 
membranes  and  complete  the  version  without  rupturing  them;  (2)  another  is  to 


VERSION.  933 

pass  the  internal  hand  up  between  the  uterine  wall  and  membranes  until  oppo- 
site the  feet  and  then  rupture;  (3)  and  the  third  is  to  rupture  the  membranes 
at  the  level  of  the  os  and  introduce  the  hand  into  the  amniotic  cavity  during 
the  escape  of  the  water.  The  first  plan  is  to-day  practically  obsolete,  and  the 
passage  of  the  hand  up  until  opposite  the  feet,  as  in  the  second  plan,  carries 
with  it  unnecessary  dangers  of  septic  infection,  accidental  hemorrhage  from 
premature  placental  separation,  and  rupture  of  the  uterus.  I  have  seen  several 
cases  of  alarming  ante-partum  hemorrhage  from  this  method.  It  is  not  to  be 
recommended.  The  third  method  of  low  rupture  is  the  safest  of  all  and  quite 
as  satisfactory  as  any  other.  In  this  method  there  is  no  danger  of  accidental 
hemorrhage ;  the  liquor  amnii  is  quite  as  readily  dammed  back  in  the  uterus  by 
the  wrist  and  forearm  in  the  vagina;  and  then  we  have  the  great  advantage  of 
working  entirely  within  the  membranes  from  the  internal  os,  they  forming,  so  to 
speak,  a  protecting  glove  covering  the  internal  hand  and  reducing  the  dangers  of 
infection  to  a  minimum  (Fig.  637). 

Further  Course  of  the  Internal  Hand. — In  the  absence  of  uterine  contraction, 
the  internal  hand  should  gradually  be  passed  within  the  bag  of  membranes  upward 
toward  the  fundus  and  along  the  lateral  uterine  wall,  disturbing  the  fetal  ellipse  as 
little  as  possible.  During  the  entire  time  the  external  hand  must  make  careful 
counter-pressure  over  the  fundus  until  the  feet  are  seized.  If  a  uterine  contrac- 
tion at  any  time  occurs,  all  upward  movements  of  the  internal  hand  must  cease 
and  the  hand  lie  flat  against  the  uterine  wall  until  the  contraction  has  passed  off. 
Some  difficulty  will  usually  be  encountered  in  passing  the  presenting  head.  This, 
as  a  rule,  can  be  overcome  by  gently  pushing  it  toward  the  iliac  fossa  opposite  the 
internal  hand.  In  late  internal  podalic  versions  in  cephalic  presentations  atten- 
tion must  be  paid  to  the  condition  and  location  of  the  contraction  ring.  Should 
one  palpate  the  contraction  ring  projecting  markedly  toward  the  fetal  head, — and 
there  is  difficulty,  under  deep  anesthesia,  of  passing  the  hand  by  this  ring, — the 
version  should  be  abandoned,  since  the  conditions  indicate  retraction  of  the  body 
of  the  uterus,  ascent  of  the  retraction  ring,  and  dangerous  thinning  of  the  lower 
uterine  segment.  There  would  be  great  danger  of  uterine  rupture  in  attempting 
to  displace  the  head  upward  and  over  such  a  retraction  ring. 

Choice  of  Leg  to  Bring  Down. — Shall  we  seize  one  or  both  feet;  and,  if  one 
foot,  the  knee  or  foot,  the  anterior  or  posterior  leg?  If  both  legs  only  are  brought 
down  and  not  one  leg  alone,  the  whole  breech  makes  a  better  dilator  for  cervix, 
vagina,  and  vulva  than  the  half  breech  (Fig.  11 22),  and  hence  the  fetal  prognosis 
is  improved  because  a  fuller  dilatation  of  the  passages  diminishes  the  danger 
of  the  after-coming  head  and  the  disengagement  of  possibly  extended  arms. 
If  the  fetus  is  dead  or  macerated;  if  it  is  small  or  medium-sized;  and  if  in  the 
interest  of  the  mother  great  haste  is  essential,  the  grasping  of  both  legs  will 
also  be  indicated.  If  both  legs  are  brought  down,  the  feet  are  seized.  There 
are  two  advantages  in  seizing  a  knee  and  not  a  foot  when  one  leg  is  brought  down 
first:  the  knee  in  a  normal  attitude  is  nearer  the  os  than  is  the  foot,  and,  second, 
the  flexure  of  the  knee  offers  a  convenient  hold.  One  foot  is  difficult  to  grasp  within 
the  uterus  without  doubling  the  hand  into  the  shape  of  a  closed  fist,  and  this  oc- 
cupies much  space.  On  the  other  hand,  the  knees  lie  near  the  elbows,  and  differ- 
entiation with  fingers  whose  sensation  is  partially  lost  by  reason  of  uterine  pres- 
sure is  not  always  easy.  To  distinguish  the  knee  from  the  elbow,  one  should 
recall  that  the  knee  is  relatively  broad,  has  not  the  sharp  projection  of  the  ole- 
cranon, and  usually  points  toward  the  head;  while  the  elbow  is  sharp  and  points 
away  from  the  head.  In  doubt,  one  can  follow  along  the  extremity  and  differenti- 
ate hand  from  foot,  or  in  the  opposite  direction  and  distinguish  shoulder  from 


934 


OBSTETRIC  SURGERY. 


breech.  When  the  knee  is  selected,  the  forefinger  is  slipped  into  the  fold  of  the 
popliteal  space,  the  knee  is  drawn  down  through  the  os  into  the  vagina,  and  the 
leg  then  extended  and  subsequent  traction  made  upon  the  leg.  As  regards  the 
choice  of  legs  when  one  is  seized,  many  authorities  state  that  it  makes  no  difference 
which  is  selected ;  that  the  best  plan  is  to  seize  whichever  comes  first  and  is  most 
readily  found.  As  stated  elsewhere,  whichever  leg  is  seized  in  version  eventually 
comes  to  the  pubic  angle,  hence  to  avoid  unnecessary  torsion  of  the  fetus  it  will 


/''.••'   ^ 


%I 


Fig.  1 129. — Difficult  Podalic  Version 
IN  Cephalic  Presentation.  Combined 
manipulation,  consisting  in  upward  pres- 
sure upon  the  head  with  the  hand  in  the 
uterus,  and  downward  traction  with  a 
sling  attached  to  a  prolapsed  leg. 


Fig.  1 130. — The  Completion  of  Podalic 
Version.  The  version  is  finished  when 
the  knee  is  at  the  vulva,  and  the  long 
axes  of  fetus  and  uterus  correspond. 


be  found  advantageous  always  to  select  the  anterior  leg.  To  sum  up,  the  plan  I 
have  found  most  successful  is  to  seize  the  knee  when  one  leg  is  to  be  brought  down 
and  the  feet  when  both.  I  always  endeavor  to  bring  down  the  anterior  leg  in 
single-leg  versions. 

Difficult  Internal  Version  in  Cephalic  Presentation. — If  one  encounters  diffi- 
culty in  the  rotation  of  the  fetus,  the  same  two  expedients  may  be  used  as  are 
made  use  of  in  difficult  internal  podalic  version  in  shoulder  presentation.  The 
manoeuvers  constitute  the  so-called  combined  manipulations.     One  is  by  me- 


VERSION.  936 

chanical  means  to  apply  greater  traction  on  the  leg  than  we  are  able  to  do  with 
the  hand;  and  the  second  is,  by  an  arrangement  of  the  soft  fillet  or  sling  to 
draw  down  on  the  leg  or  legs  while  we  push  up  the  head  internally  (Fig.  1129). 
These  methods  are  described  on  page  935,  under  "Version  in  Impacted  Shoulder 
Presentation."  It  must  ever  be  remembered  that  in  cephalic  presentation  diffi- 
cult version  by  the  combined  manoeuver  is  usually  a  more  dangerous  procedure 
for  the  integrity  of  the  uterus  than  is  an  operation  of  equal  difficulty  in  shoulder 
presentation.  Moreover,  difficult  version  in  a  cephalic  presentation  is  almost 
always  undertaken  in  the  interests  of  the  fetus;  namely,  in  malpresentations 
and  malpositions;  hence  if  the  resistance  to  the  rotation  of  the  fetus  is  very 
great,  we  must  be  careful  not  to  persist  and  thus  run  too  great  a  risk  of  uterine 
rupture. 

2.  In  Shoulder  Presentation. — The  preparation  and  the  general  principles 
are  the  same  as  in  cephalic  presentation. 

Choice  of  Internal  Hand. — Because  the  feet  are  usually  within  easy  reach  in 
the  center  of  the  uterus,  the  choice  of  hand  is  not  so  important  as  in  cephalic 
presentation.  In  general,  the  hand  should  be  used  the  palm  of  which  most 
naturally  faces  the  legs.  Thus,  in  left  scapula  positions  of  the  shoulder  I  always 
use  the  left  hand  internally  to  grasp  the  foot  or  feet,  and  in  right  scapula  posi- 
tions, the  right. 

Treatment  of  Intact  Membranes. — This  is  practically  the  same  as  in  cephalic 
presentation. 

Choice  of  Leg  to  Bring  Down. — Some  operators  attach  little  importance  to  the 
choice  between  the  upper  or  lower  leg,  and  seize  either  foot  indifferently.  In 
Germany  preference  is  given  to  the  lower  leg,  and  in  England  the  followers  of 
Simpson  teach  the  doctrine  of  selecting  the  leg  on  the  side  of  the  body  opposite 
to  the  presenting  shoulder.  I  hold  that  a  distinct  choice  exists  here,  although 
in  extreme  emergency,  when  the  time  does  not  allow  of  a  positive  diagnosis  of 
the  position,  one  is  only  too  glad  to  seize  the  first  foot  available.  A  study  of  the 
mechanism  of  labor  in  pelvic  presentation  will  convince  one  of  the  importance 
of  the  fetus  maintaining  a  dorso-anterior  position.  Further,  in  order  that  the 
fetal  attitude  may  be  disturbed  as  little  as  possible,  it  is  necessary  that  the  leg 
selected  shall  take  the  shortest  road  to  the  pubic  arch.  Both  of  these  condi- 
tions are  fulfilled  by  selecting  the  lower  leg  in  scapulo-anterior  positions,  and 
the  upper  leg  in  scapulo-posterior  positions. 

Sling  to  the  Prolapsed  Arm. — In  case  an  arm  is  prolapsed  in  the  vagina  or 
through  the  vulva,  there  should  never  be  any  attempt  at  replacing  it,  but  a 
sling  should  be  attached  to  the  wrist,  affording  a  distinct  advantage.  The 
operator  has  thus  complete  control  over  one  arm  at  least,  and  he  will  always 
be  able  to  prevent  this  arm  from  becoming  extended  above  the  head  and  so 
delaying  the  extraction  of  the  after-coming  head.     (Compare  "The  Sling.") 

Version  in  Impacted  Shoulder  Presentation. — In  instances  in  which  version  is 
demanded  after  the  membranes  have  been  ruptured  for  some  time  and  the  uterus 
is  closely  contracted  around  the  fetus,  we  may  find  much  difficulty  in  moving  the 
fetus,  after  the  leg  has  been  even  seized,  and  with  the  assistance  of  external 
manipulations.  Three  expedients  will  here  usually  prove  successful,  although  in 
the  case  of  a  dead  fetus  and  dangerous  thinning  of  the  lower  uterine  segment 
decapitation  is  the  safer  operation.  First,  an  anesthetic  to  the  full  surgical 
degree  is  demanded,  in  order  to  secure  the  greatest  possible  relaxation  of  the 
uterus.  Second,  some  means  is  employed  to  secure  more  powerful  traction  on 
the  leg  than  can  be  obtained  with  the  internal  fingers.  The  best  way  of  making 
powerful  traction  is  by  the  aid  of  the  sling  (Figs.  112S  and  1129).     Third,  the 


936  OBSTETRIC  SURGERY. 

internal  hand  is  used  not  to  draw  down  on  the  leg,  but  firmly  to  push  up  on  the 
shoulder.  The  sling  to  the  leg  leaves  ample  room  for  this,  and  we  thus  bring  two 
forces  simultaneously  into  play  on  the  opposite  poles  of  the  fetal  trunk  (Fig. 
1 129).  In  very  difficult  cases  the  second  leg  can  be  brought  down,  a  sling 
applied  to  it,  and  traction  made  on  both  legs  simultaneously. 


(D)  PELVIC  VERSION. 

Pelvic  version,  in  which  the  breech  is  caused  to  present  by  external,  com- 
bined, or  internal  manipulation,  without  a  leg  being  brought  down,  is  to-day 
rarely  performed,  being  practically  obsolete.  The  same  general  principles  as  in 
cephalic  or  podalic  version  govern  its  performance. 

Prognosis. — In  the  44  cases  analyzed  by  the  author,  one  mother  died  from  rup- 
ture of  the  uterus  following  manual  dilatation  and  internal  podalic  version  for 
placenta  praevia.  Of  the  children,  32,  or  72.5  per  cent.,  were  delivered  alive; 
7,  or  15.9  per  cent.,  were  still-bom;  i,  or  2.27  per  cent.,  died  in  the  puerperium, 
and  in  5  there  was  no  record  of  the  result.  (Compare  Forceps.)  Forceps  opera- 
tion was  attempted  in  6  cases  prior  to  the  version. 


XII.  PELVIOTOMY. 

Symphyseotomy  is  so  well,  if  not  so  favorably,  known  that  the  practitioner 
generally  ignores  the  fact  that  this  particular  form  of  intervention  is  but  one  of 
several  methods  of  dividing  the  pelvic  ring.  Double  Ischio-pubiotomy :  A  few 
years  after  Sigault's  introduction  of  symphyseotomy,  Aitken  performed  an  opera- 
tion for  enlarging  the  pelvic  cavity  by  sawing  through  the  two  rami  of  the  ischium 
and  those  of  the  pubis  on  either  side  of  the  pubic  bone.  Double  Pubiotomy :  Pitois 
modified  this  operation  by  carrying  the  incisions  through  the  pubic  bone  on  both 
sides  of  the  symphysis.  Triple  Pelviotomy :  Finally  Galbiati,  the  distinguished 
symphyseotomist,  added  ischiopubiotomy  to  symphyseotomy,  thus  dividing  the 
pelvic  ring  in  three  different  localities.  These  operations  were  practised  as  a 
variation  or  extension  of  the  principle  of  symphyseotomy,  in  cases  in  which  the 
latter  operation  could  not  sufficiently  enlarge  the  pelvic  cavity;  such  a  state  of 
affairs  could  hardly  occur  save  in  high  degrees  of  pelvic  contraction,  ankylosis,  or 
deformity,  or  in  some  condition  of  the  symphysis  in  which  its  division  is  contra- 
indicated.  Operations  dividing  the  pelvic  bones  have  been  looked  upon  as  obso- 
lete, being  supplanted,  since  the  antiseptic  era,  by  artificial  premature  delivery, 
CcBsarean  section,  etc.  However,  in  1892  Farabeuf  revived  this  principle  by 
recommending  and  practising  ischiopubiotomy  (unilateral)  in  the  asymmetrical 
ankylosed  pelvis. 

Unilateral  Ischio-pubiotomy. — This  operation,  according  to  Farabeuf,  is  one 
which  may  be  performed  by  any  practitioner  without  difficulty  or  risk.  Its 
technique  is  as  follows:  The  cutaneous  incision  should  be  parallel  with  the 
median  line  and  at  a  distance  of  i-j  inches  (4  cm.)  from  it.  The  rami  of  the 
ischium  and  those  of  the  pubis  are  thereby  exposed  sufficiently  for  the  passage  of 
a  chain-saw  around  them.  The  ramus  of  the  ischium  is  to  be  divided  by  the 
side  of  the  perineum,  to  the  right  of  the  fourchette;  the  ramus  of  the  pubis  is  to 
be  divided  a  finger's-breadth  to  the  outer  side  of  the  pubic  bone.  A  finger  should 
be  kept  in  the  vagina  during  the  various  steps  which  end  in  the  division  of  the 
ramus  of  the  pubis.     After  the  pubic  bone  has  been  exposed  by  incision  through 


SYMPHYSEOTOMY.  937 

the  soft  parts,  a  curved  rasp  is  used  to  denude  its  outer  aspect,  lower  border,  dnd 
inner  aspect  of  the  bone,  the  instrument  reappearing  at  the  obturator  fora- 
men. The  chain-saw  is  passed  around  the  bone  by  the  aid  of  a  blunt  curved 
needle,  the  soft  parts  are  pushed  back,  and  the  bone  is  sawed  through.  The 
ramus  of  the  pubis  is  divided  in  a  similar  fashion,  care  being  taken  to  respect  the 
inguinal  canal.  The  pectineal  aponeurosis  and  Gimbemat's  ligament  are  de- 
tached from  the  bone.  The  saw  can  be  passed  around  the  latter  with  very  little 
preliminary  denudation.  No  separation  of  the  bones  occurs  thus  far,  because 
it  is  prevented  by  the  obturator  membrane,  which  must  be  disconnected  from 
the  pubic  ramus.  With  the  aid  of  some  strong,  blunt  instrument  the  severed 
bones  are  now  pried  apart.  The  amount  of  separation  obtained  thereby  is  at 
least  I.I  inches  (3  cm.).  After  delivery  the  ramus  of  the  pubis  should  be  wired 
together  by  strong  metallic  sutures.  Ischiopubiotomy,  being  simply  a  variation 
of  symphyseotomy  when  the  latter  is  insufficient,  comprises  certain  principles 
which  will  be  considered  in  detail  under  the  latter  operation. 


XIII.  SYMPHYSEOTOMY. 

Symphyseotomy,  or  division  of  the  ligaments  which  unite  the  two  halves  of 
the  pubic  bone,  is  an  operation  introduced  into  obstetrical  surgery  for  the  pur- 
pose of  enlarging  the  pelvic  inlet  in  dystocia  arising  from  disproportion  between 
the  pelvis  and  the  fetal  head.  It  is  quite  radical  as  a  piece  of  operative  interven- 
tion; for  despite  the  apparent  simplicity  of  the  operation  proper,  it  may  be  re- 
garded as  a  crucial  example  of  work. 

Indications. — Symphyseotomy  may  be  regarded  as  an  independent  procedure, 
or  as  a  mere  accessory  to  version,  high  forceps  extraction,  etc.  Broadly  speaking, 
it  is  a  method  for  enlarging  the  pelvic  cavity,  and  has  many  uses  in  theory  which 
cannot  be  realized  in  practice.  Chrobak  *  states  that  there  is  hardly  an  obstetric 
operation  in  which  symphyseotomy  might  not  be  employed  as  an  adjuvant.  The 
operation  of  division  of  the  joint  itself  is  insignificant  in  its  consequences,  and  the 
real  complication  lies  in  the  injuries  necessarily  inflicted  upon  the  soft  parts. 
Hence  symphyseotomy  as  an  adjuvant  to  other  obstetric  operations  must  neces- 
sarily add  to  the  risk  already  present.  The  indications  and  contraindications  for 
symphyseotomy  necessarily  vary  with  the  point  of  view  of  the  operator.  The  in- 
tervention is  ostensibly  to  save  the  child  without  thereby  imperiling  the  life  of  the 
mother.  The  Italian  symphyseotomists,  Morisani  and  Novi,  do  not  look  upon 
premature  delivery,  Cassarean  section,  and  symphyseotomy  as  competitive  but 
as  entirely  distinct  procedures,  each  having  its  own  special  indications  and  con- 
traindications. It  is  essential  for  the  success  of  symphyseotomy  that  the  pelvis 
be  not  too  small  for  the  expulsion  of  the  child ,  for  the  subsequent  application  of  the 
forceps  must  add  greatly  to  the  risk  for  both  mother  and  child.  It  is  also  essen- 
tial that  the  child  be  able  to  come  into  the  world  alive.  Symphyseotomy  is  in- 
dicated if  the  conjugate  is  between  3.46_inches  (8.8  cm.)  and  2.64  inches  (6.7  cm.). 
If  this  condition  is  insisted  upon,  the  results  of  intervention  are  seen  to  be  excel- 
lent. It  is,  however,  regarded  as  an  error  to  make  the  indication  for  symphyseo- 
tomy depend  wholly  upon  the  dimensions  of  the  conjugate,  as  some  account  must 
be  taken  of  the  shape  of  the  pelvis  as  a  whole.  Symphyseotomy  is  especially 
indicated  in  certain  types  of  pelvic  deformity,  such  as  the  funnel-shaped  pelvis, 
sacro-coccygeal  ankylosis,  etc.   In  the  justo-minor  pelvis  the  operation  is  indicated 

*  Cited  by  Neugebauer,  p.  197. 


938 


OBSTETRIC  SURGERY. 


without  too  implicit  adherence  to  the  size  of  the  conjugate.  Other  indications 
for  symphyseotomy  are  found  in  normal  pelves  with  excessive  size  of  fetal  head, 
or  in  the  presence  of  deformities.  Neugebauer,  who  has  doubtless  devoted 
more  time  to  the  study  of  symphyseotomy  than  has  any  other  individual,  with  the 
possible  exception  of  Morisani,  states  that  the  operation  possesses  a  strict  indica- 
tion, standing  midway  between  artificial  premature  delivery  and  Cesarean  sec- 
tion, with  the  former  of  which  it  may  also  be  combined  to  save  the  life  of  the 
child.  My  experience  in  six  cases  of  flattened  and  generally  contracted  pelves 
does  not  lead  me  to  look  with  favor  upon  the  operation.  I  am  accustomed  to 
consider  the  induction  of  premature  labor  and  Cassarean  section,  and  in  special 
cases  even  embryotomy,  as  competitive  with  symphyseotomy. 

Morbidity. — Rubinrot's  analysis  teaches  us  that  the  operation  of  symphyseot- 
omy abounds  in  accidents.  The  number  of  post-operative  complications  is  not 
less  formidable.  Shock  occurs  but  rarely,  but  septic  accidents  are  present  in 
not  less  than  30  per  cent.,  this  proportion  including  mild  as  well  as  severe  forms. 
There  were  to  deaths  from  sepsis  in  136  operations.     Simple  suppuration  of  the 


Fig.  1 13 1. — Transverse  Section  of  a 
Pelvis  Just  below  the  Pelvic  Inlet, 
Mounted  upon  a  Scaled  Board  to  Il- 
lustrate Symphyseotomy. 


Fig.  1 132. — Asymmetric  Separation  at 
THE  Pubic  and  Sacro-iliac  Joints  in 
Symphyseotomy. 


symphyseotomy  wound  occurred  in  about  10  per  cent,  of  all  cases,  and  oedema  of 
the  vulva  in  nearly  the  same  proportion.  Of  the  more  unusual  post-operative 
complications  may  be  mentioned  hematoma,  abscess,  stitch-abscess,  fistula,  per- 
manent separation  of  the  pubic  bones,  lymphangitis,  cystitis,  incontinence  of 
urine,  paresis  of  the  bladder,  urinary  fistula,  bedsores  in  various  localities,  infec- 
tious myelitis,  neuralgias,  and  arthritis  or  other  disorders  of  the  sacro-iliac  syn- 
chondrosis. In  addition  to  the  foregoing,  a  more  remote  series  of  post-operative 
accidents  should  be  mentioned,  the  presence  of  which  is  apparent  for  months  after 
the  operation ;  namely,  disturbance  of  the  gait,  which  is  due  to  permanent  separa- 
tion of  the  symphysis,  sacro-iliac  disease,  etc.,  bony  sequestra,  urinary  inconti- 
nence and  fistulae,  vesical  paresis,  cystitis,  and  sepsis.  Sepsis,  the  most  redoubt- 
able post-operative  complication,  appears  to  be  connected  especially  with  hemor- 
rhage, whether  due  to  the  intervention  itself  or  to  uterine  inertia,  and  with  lacera- 
tions of  the  parturient  canal,  independent  of  coincident  hemorrhage.  In  other 
cases  no  cause  for  sepsis  is  apparent.  It  has  been  claimed  that  sepsis  after  sym- 
physeotomy is  especially  favored  by  the  jagged,  uneven  character  of  the  opera- 


SYMPHYSEOTOMY.  939 

tion-wound,  which  latter  is  in  marked  contrast  with  the  clean-cut  incisions  of 
the  Caesarean  section.  More  or  less  stormy  convalescence  followed  all  of  my  six 
cases  of  symphyseotomy. 

Mortality. — According  to  Rubinrot's  analysis  of  136  cases  of  symphyseotomy 
from  1896  to  1898,  the  combined  maternal  mortality  was  in  round  numbers  11 
per  cent.  Fifteen  of  the  women  died;  two  directly  from  the  operation  itself 
and  thirteen  from  post-operative  complications  (sepsis).  This  percentage  is  in 
harmony  with  that  obtained  by  Morisani  for  241  miscellaneous  operations  per- 
formed before  1894,  and  by  Neugebauer  in  his  analysis  of  278  cases.  In  regard 
to  the  infantile  mortality,  Rubinrot  records  19  deaths  in  136  operations,  or  nearly 
14  per  cent.  These  figures  are  higher  than  those  of  Morisani,  who  places  the  in- 
fantile mortality  at  12  per  cent.  This  contrast  is  somewhat  paradoxical,  as 
Rubinrot's  statistics  refer  to  purely  modem  operations,  while  Morisani  deals 
with  all  the  cases  since  the  first  introduction  of  the  operation.  The  infan- 
tile mortality  appears  to  be  due  to  a  variety  of  affections  and  by  no  means  neces- 
sarily to  the  operation.  A  certain  number  of  deaths  are  due  to  attempts  at 
forceps  extraction  before  the  performance  of  symphyseotomy,  as  shown  by  the 
presence  of  meningeal  hemorrhage,  fracture  of  the  skull,  etc.,  found  at  autopsy. 
Some  of  the  deaths  are  such  as  are  inevitable  in  ordinary  labor,  e.  g.,  from  pro- 
lapse of  the  cord,  eclampsia  of  the  mother,  etc.  Generally  speaking,  the  infan- 
tile mortality  is  rendered  high  by  reason  of  the  prolonged  sojourn  of  the  child  in 
the  maternal  passages,  the  use  of  anesthetics,  shock,  etc., — all  of  which  condi- 
tions tend  naturally  to  favor  still-birth,  apparent  death,  asphyxia,  etc.  A  very 
large  proportion  of  children  delivered  by  symphyseotomy  require  reanimation. 


OPERATION. 

At  the  present  time  the  operative  technique  is  practically  made  up  of  three 
distinct  methods,  each  of  which  is  upheld  by  the  operators  of  a  particular  nation- 
ality. Thus  we  have  (i)  the  French  or  open  method  as  performed  by  Pinard  and 
his  followers;  (2)  the  American  or  subcutaneous  method;  and,  finally,  (3)  the 
suprapubic  method  of  Morisani  and  his  pupils.  All  the  French  operations  from 
1896  to  1898  inclusive  were  done  in  the  classical  manner  prescribed  by  Pinard  and 
Farabeuf  save  those  of  Porak^  who  employs  a  method  of  his  own.  The  French 
method  was  also  employed  in  most  of  the  operations  outside  of  France.  Morisaini's 
method,  which  prevails  in  Italy,  was  occasionally  employed  in  other  countries, 
notably  in  America.  Several  Americans  have  operated  by  the  subcutaneous 
method,  while  Franck  in  Germany  and  Lauro  in  Italy  have  devised  modifica- 
tions of  symphyseotomy  which  go  by  their  names. 

Italian  or  Suprapubic  Method  (Fig.  1133). — The  original  method  employed 
by  Morisani,  otherwise  known  as  the  Italian  or  suprapubic  operation,  is  as  fol- 
lows: A  transverse  incision  1.18  inches  (3  cm.)  long  is  made  0.39  inch  (i  cm.) 
above  the  pubis  with  the  design  of  exposing  the  upper  margin  of  the  bone.  The 
Galbiati  knife  is  then  passed  behind  the  symphysis,  as  far  as  its  lower  border,  and 
with  a  stroke  of  the  instrument  from  behind  upward  and  from  below  upward,  the 
symphysis  is  divided.  Morisani  then  waits  for  spontaneous  expulsion,  and  if  this 
is  not  forthcoming  the  forceps  is  applied.  The  cutaneous  incision  is  then  re- 
paired and  an  immovable  dressing  of  plaster-of- Paris  or  silica  is  applied  about  the 
pelvis.  Novi's  method  is  practically  the  same,  save  that  he  uses  a  bistoury  in- 
stead of  Galbiati's  knife.  He  applies  after  the  operation  a  simple  spica_^bandage, 
not  reinforced  in  any  manner.  A  special  symphyseotome  has  been  devised  by 
Spinelli,  which  is  manufactured  in  three  sizes.     In  order  to  use  this  instrument 


940 


OBSTETRIC  SURGERY. 


the  suprapubic  incision  does  not  suffice  and  the  symphysis  must  be  laid  bare. 
Morisani  sometimes  employs  a  bistoury  in  place  of  Galbiati's  knife.    He  appears  to 
content  himself  with  a  simple  roller  bandage  to  secure  the  apposition  of  the  pelvic 
bones.  The  Italian  method  as  practised  by  Morisani 
and    Novi   is    peculiar  in  that  the    symphysis   is 
divided  from  behind  forward  and  from  below  up- 


Fig.    1 133. — The    Italian    or   Suprapubic    Method    of         Fig.  1134. — The  French  or 
Operation.  Open  Method  of  Opera- 


ward,  and  that  no  attention  is  given  to  the  insertion  of  the  recti,  or  to  the  clitoris 
and  its  vessels.      The  chief  care  lies  in  the  dissection  of  the  retropubic  tissue  to 


^      " 


'■—^ 


Fig.  1135. — Subcutaneous   or  Ayers's  Method  of  Operation. 


make  a  passage  for  the  knife.     Charpentier  (quoted  by  Neugebauer)  was  much 
impressed  by  the  singular  unanimity  of  the  Italian  operators  as  to  technique. 
French  or  Open  Method  (Fig.   1134). — Pinard's    method,  otherwise  known 


SYMPHYSEOTOMY. 


941 


as  the  French  or  open  operation,  is  as  follows.  The  mons  veneris  is  shaved, 
and  it  is  regarded  as  an  essential  step  to  make  the  incision  exactly  in  the  middle 
line.  The  skin  and  subcutaneous  tissues  are  divided,  the  incision  being,  as  a 
rule,  3.15  to  3.9  inches  (8  to  10  cm.)  in  length,  extending  from  above  the  pubis  to 
just  above  the  clitoris,  deviating  a  little  from  the  middle  line  in  order  to  avoid 
wounding  the  vessels  of  the  clitoris.  The  insertion  of  the  recti  is  divided  in  the 
upper  angle  of  the  wound,  so  that  the  finger  may  enter  the  prevesical  space  and 
protect  the  bladder.  The  symphysis  is  then  divided  with  a  few  strokes  of  the 
knife  from  above  downward  and  from  before  backward.  If  the  separation  of  the 
pubic  bones  is  insufficient,  Pinard  has  his  assistants  enlarge  the  breach  by  ap- 
propriate pressure  upon  the  lower  extremities.  The  ligamentous  mass  beneath 
the  symphysis  is  divided  last  of  all.  Before  waiting  for  the  expulsion  of  the 
child,  the  symphysis  is  carefully  examined  to  see  if  detachment  is  "nearly 
complete.  If  convinced  that  the  sacro-iliac  articulation  will  permit  sufficient 
separation  of  the  pubic  bones,  Pinard  immediately  applies  a  temporar}'-  dress- 
ing to  the  cutaneous  wound  and  leaves  to  the  patient  the  task  of  expelling  the 
fetus.  In  the  open  method  some  operators  insert  periosteal  sutures  into  the 
pubic  bones  before  closing  the  cutaneous  wound,  and  one  accoucheur,  Fieux, 
of  Bordeaux,  regards  this  periosteal  suture  as 
quite  sufficient  for  immobilizing  the  pelvis. 
Others  employ  mechanical  devices  to  retain 
the  pelvic  bones  in  apposition. 

Subcutaneous  or  Ayers's  Method  (Fig. 
1 13 5). — The  subcutaneous  method  is  per- 
formed as  follows:*  If  possible,  the  cervix 
must  be  fully  dilated;  the  urethra  and  blad- 
der are  to  be  held  to  one  side  with  a  sound. 
The  initial  incision  must  be  made  a  little 
above  the  subpubic  arch  and  under  the  ele- 
vated clitoris.  The  left  index-finger  is  intro- 
duced within  the  vagina  and  held  against  the 
posterior  aspect  of  the  joint.  A  narrow  tenot- 
omy knife  is  then  passed  up  to  a  point  within  half  an  inch  of  the  summit  of  the 
joint  beneath  the  overlying  soft  tissues.  A  probe-pointed  bistoury  is  then  sub- 
stituted for  the  tenotome  and  carried  to  the  top  of  the  joint,  where  it  meets  the 
index-finger.  It  is  then  carried  downward  through  the  joint  until  the  latter  is 
felt  by  the  index-finger  behind  to  give  way.  An  assistant  now  presses  a  small 
gauze  compress  against  the  incision  beneath  the  clitoris.  If  possible,  the  child  is 
then  delivered  with  the  forceps.  When  pressure  is  made  upon  the  pubic  bones, 
the  bladder  must  be  held  to  one  side.  A  small  piece  of  gauze  is  next  forced  into 
the  wound  while  another  strip  is  left  in  the  cervix.  The  operator  must  refrain 
from  immediate  repair  of  the  cervix  or  perineum  if  the  latter  is  torn.  A  soft- 
rubber  retention  catheter  is  left  in  the  bladder  until  the  power  of  voluntary  mic- 
turition returns.  The  vulva  is  dressed  with  gauze  and  the  pelvis  strapped  with 
adhesive  strips.  All  the  gauze  is  removed  in  thirty-six  hours  and  the  vulva  and 
vagina  are  irrigated  twice  daily,  the  vulva  being  carefully  dressed  between 
times  (Fig.  1136). 

*Ayers:  "The  Pubic  Symphysis  in  Parturition,"  "  Amer.  Jour,  of  Obstetrics  and  Dis. 
of  Women  and  Children,"  July,  1S97. 


Fig.  1 136. — Mechanical  Brace  for 
Holding  the  Joint  after  Sym- 
physeotomy. 


942  OBSTETRIC  SURGERY. 


XIV.   EMBRYOTOMY  IN  GENERAL. 

Much  ambiguity  has  arisen  from  the  defective  terminology  of  the  mutilating 
operations.  There  is  not  a  word  in  general  use  to  designate  collectively  all  these 
forms  of  intervention.  Embryulcia,  a  word  possessing  this  general  significance, 
is  used  by  a  few  only.  Embryotomy,  which  literally  means  mutilation  of  any 
portion  of  the  fetus,  does  not,  with  most  authors,  include  operations  upon  the 
skull,  which  are  comprised  indifferently  under  the  terms  craniotomy  and  perfora- 
tion. In  this  narrow  sense  embryotomy  comprises  the  operations  of  decapita- 
tion, cleidotomy,  eventration,  amputation,  etc.  The  absence  of  a  general  des- 
ignation to  include  all  these  operations  has  led  to  the  omission  by  many  writers 
of  a  general  section  upon  embryotomy  in  the  wider  sense — its  indications,  fre- 
quency, prognosis,  etc. 

Definition. — Embryotomy  comprises  all  operations  upon  the  fetus  which 
have  for  their  object  a  sufficient  reduction  in  size  to  make  extraction  possible 
by  the  natural  passages. 

Varieties. — Embryotomy  includes  all  degrees  of  mutilation,  from  simple  acts 
like  cleidotomy  and  rachidotomy  to  complete  morcellation  of  the  fetus.  It  is  per- 
formed upon  both  the  dead  and  the  living  child,  and  by  reason  of  the  feticide  in- 
volved in  the  latter  case,  the  indications  naturally  diverge  widely  according  to 
the  state  of  the  child  and  the  point  of  view  of  the  operator,  since  feticide  is  justifi- 
able only  when  the  mother's  life  would  otherwise  be  sacrificed. 

Embryotomy  in  general,  irrespective  of  the  state  of  the  fetus,  comprises  the 
following  operations:  (i)  Perforation  of  the  skull.  (2)  Perforation  of  the 
spine,  or  rachidotomy.  (3)  Crushing  or  comminution  of  the  bones  of  the 
skull — cranioclasis,  cephalotripsy,  basiotripsy.  (4)  Separation  of  the  fetal  head 
from  the  body — decapitation.  (5)  Opening  of  the  thoracic  and  abdominal 
cavities,  and  removing  the  whole  or  a  part  of  their  contents — evisceration.  (6) 
Amputation  of  extremities.  (7)  Division  of  one  or  both  clavicles — cleidotomy. 
(8)  Division  of  the  spine,  or  spondylotomy. 

Frequency. — Embryotomy  is  the  oldest  of  all  the  methods  of  intervention  in 
difficult  labors.  Version,  known  during  the  classic  period,  subsequently  became 
a  lost  art  until  revived  in  the  sixteenth  century.  With  the  gradual  introduction 
of  version  and  the  forceps  the  field  of  embryotomy  became  much  restricted, 
and  it  came  to  be  regarded  almost  as  a  resource  of  the  unskilful.  Early  in 
the  nineteenth  century  a  few  obstetricians  expressed  themselves  in  favor  of  doing 
away  entirely  with  the  operation  as  having  no  legitimate  field.  Nevertheless  it 
holds  a  secure  position  to-day  as  regards  its  employment  upon  the  dead  fetus. 
The  explanation  of  its  permanency  is  found  it  its  comparative  innocuousness. 
Whereas  the  maternal  mortality  was  once  very  high,  it  is  at  present  the  reverse. 
The  reasons  for  this  are  to  be  found  in  improvement  in  fixing  the  indications,' 
a  proper  technique,  and  asepsis  and  antisepsis.  During  the  past  fifteen  years 
I  have  had  exceptional  opportunities  to  test  every  variety  of  embryotomy  upon 
the  dead  fetus  in  the  Bellevue  Hospital  maternity  service.  To  this  service 
are  brought  every  year  cases  of  neglected  prolapsed  cord,  impacted  shoulder 
presentation,  hydrocephalus,  persistent  occipito-posterior  positions,  persistent 
mento-posterior  positions,  monsters,  eclampsia,  and  pelvic  contraction,  which 
have  been  abandoned  by  midwives  and  physicians.  It  is  from  this  extended 
clinical  experience  in  the  operating  room,  and  not  from  laboratory  or  theoretical 
deductions,  that  I  can  speak  of  the  comparative  innocuousness  of  embryotomy, 
when  properly  performed  and  when  the  pelvis  is  not  absolutely  contracted. 
In  the  forties  it  was  customary  at  the  Dublin  Rotunda  Hospital  to  end  about 


EMBRYOTOMY  IN   GENERAL.  943 

one  labor  in  loo  by  embryotomy.  In  hospital  practice  in  Germany  in  the 
seventies  and  eighties  there  was  one  embryotomy  in  every  300  to  500  labors; 
while  in  private  practice  the  proportion  was  about  1:1500.  In  2200  hospital 
cases  of  confinement  I  find  a  record  of  six  embryotomies.  The  indications 
were  as  follows:  Deformed  pelves,  2;  hydrocephalus,  2;  albuminuria,  i;  epi- 
lepsy, I.  All  the  operations  were  examples  of  craniotomy.  The  maternal 
mortality  was  o  per  cent. 

Indications. — Embryotomy  is  indicated  to-day  in  but  two  conditions. 
First,  in  all  instances  in  which  the  fetus  is  dead  and  delivery  of  the  unmutilated 
fetus  would  increase  the  danger  for  the  mother.  Second,  upon  the  living  fetus 
in  obstructed  labor  due  to  monstrosity;  and  in  exceptional  cases  in  which  the 
mother's  condition,  from  hemorrhage,  repeated  attempts  at  delivery,  sepsis, 
or  shock,  is  such  as  to  render  embryotomy  by  far  the  safer  operation. 

Although  modern  obstetrics  demands  that  embryotomy  upon  the  living 
fetus  shall,  with  the  two  above  exceptions,  never  be  performed,  still  two  cir- 
cumstances may  greatly  embarrass  the  physician  in  the  performance  of  what 
is  clearly  his  duty.  One  is  the  refusal  of  the  mother  and  her  family  to  accept 
Cesarean  section  in  the  presence  of  the  relative  indication,  and  the  other  is  the 
varied  conditions  of  environment  under  which  the  physician  and  patient  are 
often  placed.  In  the  city  or  town  a  physician  can  refuse  to  perform  embry- 
otomy upon  a  living  fetus,  as  there  are  always  competent  practitioners  at  hand 
to  whom  the  case  can  be  transferred.  In  the  sparsely  settled  country  districts 
the  physician  is  occasionally  brought  face  to  face  with  an  obstetric  complica- 
tion which  demands  an  immediate  operation  in  order  to  save  the  mother's  life. 
I  know  of  several  such  cases.  One  was  in  the  mountains  of  northern  New  York, 
in  which,  during  a  three-day  blizzard,  a  physician  was  unable  to  secure  assist- 
ance in  a  case  of  maternal  dystocia  from  a  generally  contracted  pelvis,  and 
was  compelled  to  do  an  embryotomy  to  save  the  life  of  the  mother.  Who  can 
say  that  embryotomy  under  such  circumstances  was  criminal?  This  same 
case  was  subsequently,  in  her  second  pregnancy,  sent  to  me  in  New  York,  and 
I  delivered  her  of  a  living  child.  Some  practitioners  who  repudiate  the  opera- 
tion of  embryotomy  propose  that  one  shall  wait  for  the  fetus  to  die  from  birth- 
pressure,  in  order  that  the  operation  can  be  performed  without  compunction. 
This  is  a  hazardous  and  possibly  a  fatal  concession.  For  therapeutic  feticide 
see  page  888. 

Embryotomy  upon  the  Dead  Fetus. — Embryotomy  upon  the  dead  fetus  is  de- 
manded when,  the  absolute  indication  for  Cesarean  section  being  absent,  the 
extraction  of  the  fetus,  undiminished  in  size,  would  increase  the  dangers  to  the 
mother. 

1.  This  indication  includes  moderate  degrees  of  pelvic  contraction,  malpres- 
entations  and  malpositions,  deformities  of  the  fetus,  and  slight  obstruction  in 
the  soft  parts. 

2.  In  markedly  contracted  pelves,  with  a  transverse  diameter  at  the  inlet  of 
at  least  3  inches  and  a  true  conjugate  but  little  under  2  J  inches,  embryotomy 
will  be  indicated. 

3.  In  instances  in  which  the  conjugata  vera  is  much  under  2I  inches,  when 
labor  is  obstructed  by  a  fixed  pelvic  tumor,  an  extensive  exostosis,  or  an  ad- 
vanced cancer  of  the  cervix,  celiotomy  is  to  be  preferred,  whether  the  fetus  is 
dead  or  alive. 

4.  When  the  mother's  condition  demands  rapid  delivery,  and  the  absolute 
indication  for  Caesarean  section  is  absent. 

Embryotomy  ttpon  the  Living  Fetus. — i.   Embryotomy  upon  the  living  fetus 


944  OBSTETRIC  SURGERY. 

is  indicated  during  labor  in  certain  rare  instances,  when  the  condition  of  the 
mother,  as  shown  by  the  temperature,  pulse,  dangerous  thinning  of  the  lower 
uterine  segment,  whether  from  repeated  unsuccessful  attempts  at  delivery  or 
from  prolonged  labor,  would  render  embryotomy  by  far  the  safer  operation. 
2.  In  obstructed  labor  due  to  monstrosities. 


XV.    PERFORATION. 

Definition.^-Perforation  consists  in  opening  the  fetal  skull,  incising  the 
meninges  and  brain  in  various  directions,  and  removing  the  latter  by  irrigation. 
Perforation  of  the  fetal  pelvis  through  the  anus  is  occasionally  performed. 

Indications. — (See  Embryotomy,  page  942.) 

Operation. — In  most  cases,  if  only  for  ethical  reasons,  an  anesthetic  should  be 
given.  The  patient  should,  of  course,  not  be  allowed  to  see  the  child.  The 
bladder  and  rectum  should  be  emptied  and  the  vagina  properly  cleansed  with 
lysol  or  creolin.  The  patient  should  be  in  the  lithotomy  position  with  the  hips 
drawn  well  over  the  edge  of  a  table.     The  operator  should  now  make  a  careful 


Fig.    1137. — Smellie's  Scissors  Perforator. 

examination  in  order  to  confirm  the  necessity  for  the  operation.  Three  types 
of  perforator  are  in  use:  namely,  the  scissors  (Fig.  1137);  the  screw  with  the 
hidden  knife;  and  the  trephine  perforator.  In  an  emergency  almost  any  cut- 
ting instrument  can  be  used;  thus,  twice  in  consultation  I  have  opened  the  skull 
without  a  classical  perforator,  once  using  an  ordinary  pair  of  scissors,  and  again  a 
scalpel.  Before  perforating,  especially  in  high  positions  of  the  presenting  part,  the 
head  should  be  firmly  fixed.  This  is  done  either  by  suprapubic  pressure  or  by  fixa- 
tion with  a  strong  volsella  forceps.  I  prefer  the  latter  (Fig.  1139).  A  principle  in 
perforation  too  often  neglected  and  misrepresented  in  many  works  on  obstetrics  is 
the  proper  location  of  the  opening  into  the  skull.  Our  aim  should,  always  be  so 
to  locate  this  opening  that  subsequent  traction  with  the  cranioclast  (cranio- 
traction)  will  imitate  the  natural  mechanism  of  labor.  I  have  records  of  a 
number  of  cases  in  which  craniotraction  has  been  made  with  the  cranioclast 
applied  over  the  forehead  and  face  in  vertex  presentation,  thus  extending  the 
head  and  causing  impaction  even  after  perforation;  and  over  the  forehead  and 
sinciput  in  face  presentation,  thus  flexing  a  greater  diameter  into  the  birth 
canal;  and  over  the  occiput  in  head-last  cases,  producing  the  same  result.  In 
all  instances  care  must  be  taken  to  introduce  the  perforator  deep  enough  into 
the  skull  thoroughl}^  to  break  up  the  base  of  the  brain  and  the  medulla,  for 
possibly  a  mistaken  diagnosis  may  result  in  the  extraction  of  a  mutilated  child 


PERFORATION. 


945 


making  attempts  at  respiration,  than  which  no  greater  horror  exists  in  mid- 
wifery. The  fetal  scalp  being  seized  by  a  volsella  forceps  and  the  head  drawn 
downward  into  the  pelvis  as  far  as  pos- 
sible, an  assistant  grasps  the  head 
through  the  abdominal  walls  and  fixes 
it  in  the  pelvic  inlet.  The  fingers  of 
the  left  hand  are  carried  up  behind  the 
symphysis  and  their  palmar  surfaces 
guide  the  introduction  and  subse- 
quent movements  of  the  perforator, 
which  is  inserted  with  the  right  hand 
and  carried  slowly  and  cautiously  by 
a  twisting  or  boring  movement 
through  the  fetal  skull.  A  suture  or 
fontanelle  may  be  utilized,  but  it  is 
better,  except  in  simple  cases,  to  make 
the  opening  in  one  of  the  cranial  bones, 
since  in  the  latter  case  it  is  not  so  likely 
to  become  closed  and  difficult  to  find 
again.  Every  care  should  be  taken 
that  the  instrument  does  not  slip  and 
bury  itself  in  the  maternal  tissues. 
After  the  perforator  has  entered  the 
skull  as  far  as  the  shoulders  of  the  in- 
strument it  should  be  twisted  about 
several  times  in  order  to  enlarge  the 
opening.  The  blades  may  also  be  sep- 
arated in  different  directions  for  the 
same  purpose.     It  is  then  carried  into 

the  skull  and  twisted  in  every  direction  in  order  to  break  up  the  brain  and  facil- 
itate its  removal.     If  the  trephine  perforator  is  used,  it  is  held  against  the  skull 

by  the  fingers  of  the  left 
hand,  the  right  hand  steady- 
ing the  shank  of  the  instru- 
ment. The  crank  is  turned 
by  an  assistant.  Whatever 
instrument  is  used,  care 
should  be  taken  to  remove 
with  the  forceps  all  spiculae 
of  bone,  and  the  scalp 
should,  if  possible,  be  made 
to  cover  the  edges  of  the 
opening  in  order  to  protect 
the  maternal  tissues.  The 
cranial  contents  are  then 
washed  out  as  far  as  possible 
by  means  of  a  flexible  tube 
or  catheter  attached  to  a 
syringe.  The  ordinary  foun- 
tain syringe  will  be  found 
useful.  An  antiseptic  solution  should  be  used,  and  in  the  case  of  a  putrid  fetus 
the  vagina  should  be  frequently  douched  during  the  whole  operation.  If  perfor- 
60 


Fig. 


1 138. — Perforation    of    the    After- 
coming  Head. 


Fig.   1 139. — Perforation  of  the  Fetal  Skull. 


946  OBSTETRIC  SURGERY. 

ation  and  evacuation  of  the  cranial  contents  do  not  reduce  the  size  of  the  fetal 
head  sufficiently  to  permit  safe  delivery,  it  ma}'  be  necessary  to  resort  to  the 
additional  operation  of  cranioclasm  or  craniotripsy  (pages  947  and  951). 

Pelvic  Presentation. — Perforation  may  occasionally,  in  contracted  pelves 
and  with  monsters,  be  applied  with  advantage  to  the  breech  if  it  fails  to  descend, 
and  traction  with  the  forceps,  fillet,  blunt  hook,  or  upon  a  prolapsed  leg  is  impos- 
sible or  dangerous.  An  opening  is  made  by  way  of  the  anus  through  the  fetal 
pelvis  and  the  abdominal  contents  are  "  churned  up  "  and  removed  by  irrigation 
(Fig.  II47)- 

After-coming  Head  (Fig.  1146). — Three  sites  for  perforation  are  pro- 
posed by  different  authorities,  namely,  the  posterior  lateral  fontanelle  behind 
the  ear,  the  occipital  bone,  and  the  fioor  and  roof  of  the  mouth  through 
the  hard  palate.  Many  lives  have  been  sacrificed  by  unskilful  and  prolonged 
attempts  to  perforate  and  extract  after  opening  the  brain  in  the  first  two 
localities,  since  extension  of  the  head  results,  and  the  obstruction  is  often  thus 
increased  instead  of  diminished.  In  most  cases  the  after-coming  head  should  be 
perforated  through  the  floor  and  roof  of  the  mouth,  then  through  the  hard  palate 
into  the  brain.  The  head  can  then  be  extracted  by  flexing  it.  In  those  very  rare 
cases  in  which  the  chin  rides  up  over  the  symphysis  and  cannot  be  gotten  at, 
the  head  must  be  delivered  by  extension  after  perforation  through  the  occipital 
bone. 

Vertex  Presentation  (Figs.  1143,  1145)- — Both  in  occipito-anterior  and 
-posterior  positions  it  is  best  to  perforate  toward  the  occipital  end  of  the  head- 
lever,  so  that  subsequent  traction  will  flex  rather  than  extend  the  head.  If 
cutting  instruments  are  used,  I  have  found  that  it  makes  little  difference  whether 
a  suture,  fontanelle,  or  solid  bone  is  selected  for  perforation;  if  the  trephine  is 
used,  a  bone,  preferably  the  posterior  portion  of  a  parietal,  is  selected. 

Bregma  Presentation. — It  is  best  to  return  the  head  to  its  natural  condition 
of  flexion,  or  if  this  is  impossible  to  perforate  as  near  the  occipital  bone  as  pos- 
sible (Fig.  1143)- 

Brow  Presentation. — If  the  brow  cannot  be  converted  into  a  vertex  and 
perforated  accordingly,  it  should,  if  possible,  be  changed  into  a  face.  If  impac- 
tion persists,  the  perforation  should  be  made  at  the  junction  of  the  nasal  and 
frontal  bones. 

Face  Presentation  (Fig.  1144).  —  Perforation  at  the  root  of  the  nose 
through  the  frontal  bone  gives  the  best  results  for  subsequent  craniotraction. 


XVI.    RACHIDOTOMY. 

This  operation  consists  in  making  a  slight  opening  in  the  vertebral  canal. 
The  operation  was  proposed  by  Van  Heuvel  in  1848,  but  was  not  carried  out  until 
twenty  years  later  by  Tamier.  Rachidotomy  is  employed  only  when  a  hydro- 
cephalic fetus  presents  by  the  breech  with  retention  of  the  head.  The  operation 
has  been  used  to  some  extent  by  Tamier  and  his  pupils.  Failure  can  occur  only 
through  a  disorganized  state  of  the  spinal  column  as  a  result  of  excessive  trac- 
tion. 

Technique, — An  incision  is  made  down  to  the  middle  of  the  vertebral  column. 
A  sound  provided  with  a  mandril  is  then  forced  through  the  vertebrae  and  thrust 
into  the  spinal  canal  from  below  upward  till  it  reaches  the  cranial  cavity,  when 
the  liquid  is  allowed  to  drain  away. 


CRANIOCLASIS.     CRANIOTRACTION. 


947 


XVII.   CRANIOCLASIS.     CRANIOTRACTION. 

Definition. — Cranioclasis  signifies  the  crushing  or  comminuting  of  the  bones 
of  the  skull  within  the  scalp  and  without  removing  them.  The  operation  is  per- 
formed with  an  instrument  known  as  a  cranioclast,  of  which  Karl  Braun's  is 
to-day  the  most  perfect  type.  Others  are  Kehrer's,  Simpson's,  and  Auvard's. 
The  cranioclast  is  not  only  a  crusher  but  a  tractor;  thus,  when  the  fetal  skull  is 
securely  seized  by  the  two  blades  of  the  instrument  it  serves  as  a  most  convenient 
handle  to  extract  the  head  and  fetal  body.  To-day  perforation  and  cranio- 
clasis are  usually  immediately  followed  by  extraction,  with  the  cranioclast  as  a 
tractor.     The  procedure  then  becomes  craniotraction. 

Indications. — (See  Embryotomy,  page  942.) 

Necessary  Conditions. — (i)  The  pelvis  must  not  be  so  greatly  contracted  that 
the  fetal  trunk  cannot  pass.  A  true  conjugate  of  over  2^  inches  (6.5  cm.)  is 
necessary  at  full  term.  I  believe  it  is  generally  conceded  that  cranioclasis 
and  extraction  through  a  pelvis  represented  by  a  conjugata  vera  of  2+  inches 
(6.5  cm.)  or  under  is  equally  as  dangerous  as  Cassarean  section.     (2)  In  difficult 


Fig.    1 140. — Braun's  Cranioclast. 


trunk  extractions  the  operator  should  never  neglect  to  do,  in  addition,  a  clei- 
dotomy — an  operation  much  neglected  in  these  cases. 

Operation. — Instruments. — The  original  cranioclast,  the  device  of  Sir  James 
Y.  Simpson,  was  an  evolution  of  the  ancient  craniotomy  forceps  and  was  in- 
tended by  him  to  replace  the  cephalotribe.  (See  page  947.)  It  was  proposed  with 
this  instrument,  the  solid  blade  of  which  was  introduced  into  the  perforated  skull 
and  the  fenestrated  blade  upon  the  anterior  portion  of  the  skull,  to  wrench  off  the 
bones  of  the  calvarium,  different  portions  being  successively  seized,  and  subse- 
quently to  use  the  instrument  as  a  tractor  to  deliver  the  remainder  of  the  skull. 
Braun's  cranioclast  is  intended  to  act  primarily  as  a  tractor  and  never  as  a  bone 
forceps  to  break  up  and  remove  the  vault  of  the  skull.  The  instrument  as  sup- 
plied to-day  by  the  makers  consists  of  an  exaggerated  bone  forceps  made  entirely 
of  metal  with  a  cephalic  curve  to  the  blades  and  the  shanks  and  handle  so  long 
that  the  lock  is  outside  the  vulva  even  when  the  instrument  is  introduced  high  up 
(Fig.  1 140).  A  hand-screw  at  the  end  of  the  handles  aids  compression.  The 
blades,  as  in  the  Simpson's  cranioclast,  consist  of  a  larger  or  outer  blade,  fen- 
estrated and  grooved,  which  goes  on  the  outer  surface  of  the  head  over  the  scalp, 
and  a  smaller  or  inner  blade,  solid  and  supplied  with  ridges  which  fat  into  the 
grooves  upon  the  opposite  or  outer  blade.  Although  Braun's  cranioclast  pri- 
marily was  intended  as  a  tractor  alone,  still  I  have  found  it  most  valuable  as  a  com- 
minuter  of  the  bones  of  the  calvarium  by  applying  the  instrument  successively 


948 


OBSTETRIC  SURGERY. 


over  different  portions  of  the  perforated  skull  and  crushing  the  bones  underneath 
the  scalp  without  attempting  to  remove  the  fragments,  but  bringing  all  away 
when  the  instrument  is  used  as  a  tractor.  The  term  "  cranioclast  "  as  applied  to 
the  Braun  instrument  is  a  misnomer,  and  the  term  "craniotractor,"  as  proposed 
by  Mund^,  of  New  York,  as  a  substitute  for  "cranioclast,"  is  more  accurate. 

Application. — The  application  of  the  cranioclast  is  not  difficult.  Unfortu- 
nately, for  some  reason  the  instrument  is  always  made  for  application  upon  the 
right  side  of  the  pelvis,  and  for  proper  application  upon  the  left  side — the  most 
frequent  operation — the  instrument  must  be  reversed,  with  the  button-lock  down- 
ward. This  has  caused  much  confusion  to  the  novice  and  beginner,  and  many 
applications  of  the  instrument  over  the  face,  when  a  vertex  application  would 
have  rendered  the  extraction  much  easier.     After  perforation  and  the  washing 

away  of  the  brain,  if  the  head  is  movable  the 
scalp  is  seized  with  strong  volsella  forceps  and 
held  by  an  assistant.  The  operator  then  in- 
troduces two  fingers  of  the  left  hand  to  the 
margin  of  the  opening  in  the  fetal  skull,  and 
with  the  right  hand  he  grasps  the  inner  or 


Fig      1 141. — Elongation     of    the  Fig.   1142. — Depression  in  the  Right  Parietal 

Head   after    Perforation    and  Bone,   Caused    by   Extraction   with  Braun's 

the  Use  of  the  Cranioclast. —  Cranioclast. — {Author's  collection  0}  fetal  skulls.) 
(Author's  case.) 


solid  blade  of  the  cranioclast  like  the  blade  of  a  forceps  and  introduces  it 
along  the  fingers  of  the  left  hand  as  a  guide  into  the  opening  in  the  skull. 
The  handle  is  then  held  by  an.  assistant.  Now  if  the  portion  to  be  seized 
is  along  the  left  side  of  the  pelvis,  the  outer  or  fenestrated  blade  is  seized 
like  the  blade  of  a  forceps  with  the  left  hand,  the  right  hand  is  passed  into  the 
vagina,  and  the  fenestrated  blade  is  then  introduced  along  the  fingers  of  the 
right  hand  between  the  fetal  skull  and  the  wall  of  the  parturient  canal,  care  being 
taken  not  to  include  the  cervix,  an  accident  of  not  rare  occurrence.  In  application 
in  the  left  half  of  the  pelvis  the  fenestrated  blade  must  be  introduced  under  the 
solid  blade,  so  that  the  lock  looks  downward.  The  handles  are  now  taken  one  in 
each  hand  and  the  lock  is  adjusted  and  compression  is  made  with  the  screw  on  the 
handle,  care  being  taken  that  none  of  the  maternal  parts  are  included  in  the 
instrument  and  that  the  solid  blade  is  well  sunken  in  the  cavity  of  the  skull. 
Rotation  of  the  presenting  part  with  the  cranioclast  is  a  subject  still  in  dispute. 


CRANIOCLASIS.     CRANIOTRACTION.  949 

A  twisting  corkscrew-like  motion  with  the  instrument,  as  recommended  by  some 
operators,  I  have  found  unnecessary  and  dangerous,  since  spiculae  of  bone  do 
occasionally  in  difiEicult  cases  perforate  the  skull,  and  these  readily  lacerate  the 
adjacent  maternal  soft  parts,  and  the  operator  is  not  always  able  to  detect  these 
perforations  of  the  scalp.  Rotation  with  the  instrument,  however,  in  order  to 
bring  the  vertex  or  chin  anteriorly  is  permissible  and  advisable,  as  in  forceps 
operations.  In  ordinary  cases  reapplication  of  the  instrument  and  comminution 
of  the  bones  will  not  be  found  necessary.  Traction  is  now  cautiously  made  in 
the  axis  of  that  portion  of  the  pelvis  in  which  the  head  or  breech  lies,  and  if  no 
slipping  of  the  instrument  occurs,  the  amount  of  traction  is  gradually  increased 
so  as  to  cause  the  perforated  skull  to  mold  itself  to  the  shape  of  the  pelvis,  and 
to  bring  the  cranioclast  away  from  the  side  of  the  parturient  tract  into  the 
middle  of  the  pelvis. 

Left  Vertex  Positions. — The  cranioclast  should  be  applied  so  as  to  include 
the  occipital  bone  (Fig.  1143). 

Right  Vertex  Positions. — As  in  left  positions,  the  best  result  is  obtained 
by  application  over  the  occipital  bone. 

Bregma  Presentation. — The  best  results  are  obtained  by  grasping  the 
occipital  end  of  the  head-lever  and  if  necessary  rotating  the  occiput  with 
the  cranioclast  to  the  front  of  the  pelvic  outlet  (Fig.  1143). 

Brow  Presentation. — If  the  brow  cannot  be  converted  into  a  vertex,  the 
cranioclast  is  applied  as  in  face  presentation  (Fig.  1144). 

Face  Presentation. — The  solid  blade  is  passed  into  the  skull  through 
an  opening  in  the  frontal  bone  at  the  root  of  the  nose,  and  the  fenes- 
trated blade  is  made  to  include  the  lower  jaw  (Fig.  1144).  The  other  two 
sites  of  application — namely,  the  sides  of  the  head  and  the  occipital  region — 
are  always,  if  possible,  to  be  avoided.     (See  Perforation,  page  944.) 

After-coming  Head. — Application  of  the  solid  blade  through  a  perforation 
passing  up  through  the  floor  and  roof  of  the  mouth  (hard  palate)  and  the  fen- 
estrated blade  over  the  face  will  give  the  best  prognosis,  as  flexion  of  the  head  is 
thereby  insured  (Fig.  1146).  In  exceptional  cases  in  which  the  chin  rides  up 
over  the  symphysis,  the  occipital  application  and  delivery  of  the  head  by  ex- 
tension may  become  necessary. 

Breech  Presentation. — The  solid  blade  is  passed  into  the  anus  and  the  fen- 
estrated blade  is  applied  over  the  sacrum  (Fig.  1147). 

Persistent  or  Permanent  Occipito-posterior  Position  (Fig.  1145). — Our 
aim  should  be  to  secure  a  firm  hold  with  the  instrument  over  the  occipital  bone  in 
order  to  exaggerate,  if  possible,  the  existing  flexion  of  the  head.  The  solid  blade 
enters  the  skull  at  or  near  the  small  fontanelle,  and  the  fenestrated  blade,  if  pos- 
sible, is  adjusted  over  the  center  of  the  occipital  bone,  which  latter,  of  course,  is  in 
the  hollow  of  the  sacrum.  In  difficult  cases  an  application  made  to  the  side  of  the 
head  over  a  limb  of  the  lambdoidal  suture  will  be  found  necessary  on  account  of 
the  difficulty  in  applying  the  instrument  in  the  sacral  hollow  over  a  tightly  fit- 
ting head.  Less  injury  to  the  maternal  soft  parts  will  result  if  we  can  gradually 
with  our  downward  traction  rotate  the  occiput  into  an  anterior  position.  This 
rotation  of  the  head  with  the  cranioclast  is,  under  such  circumstances,  not  only 
justifiable  but  advisable,  as  by  so  doing  a  mechanism  of  labor  much  more  favor- 
able for  the  maternal  prognosis  is  obtained.  Great  caution  should  be  exer- 
cised, should  it  be  found  necessary,  after  failure  of  anterior  rotation,  to  deliver 
with  the  occiput  to  the  rear.  This  with  full-sized  heads  should  never  be  at- 
tempted until  after  the  head  has  been  well  elongated  with  the  cranioclast,  and,  if 
thought  necessary,  comminuted  as  well  (Fig.  1141). 


950 


OBSTETRIC   SURGERY. 


Fig.  1 143. — Application  and  Use  of  the 
Cranioclast  in  a  Left  Occipito-pos- 
TERioR  Position  of  the  Vertex.' 


Fig.  1144. — Application  and  Use  of  the 
Cranioclast  in  a  Right  Menio-pos- 
terior  Position  of  the  Face. 


Fig.  1 145. — Application  and  Use  of  the 
Cranioclast  in  a  Persistent  Occipj- 
to-posterior  Position. 


Fig.  1 146. — Application  and  Use  of  the 
Cranioclast  in  Case  of  an  After- 
coming  Head. 


Pig.  1 147. — Cranioclast  Applied  to  the 
Breech,  in  Left  Sacro  anterior  Posi- 
tion. 


Fig.  1148. — Application  of  the  Cranio- 
clast to  the  Decapitated  Head  in 
Utero. 


CEPHALOTRIPSY. 


951 


Persistent  Mento-posterior  Position  (Fig.  1144). — No  matter  how  great 
the  temptation  to  apply  thecranioclast  over  the  forehead,  this  should  alwavs  be 
avoided  in  face  presentation,  and  the  instrument  applied  to  the  chin  end  of  the 
presenting  lever.  This  can  be  accomplished  by  passing  the  solid  blade  into  an 
opening  at  the  root  of  the  nose,  and  applying  the  fenestrated  blade  so  as  to  include 
the  lower  jaw  (Fig.  1144).  This,  as  in  permanent  occipito-posterior  position, 
necessitates  the  adjustment  of  the  fenestrated  blade  in  the  hollow  of  the  sacrum,  a 
manoeuver  sometimes  attended  with  much  difficulty.  Under  such  circum- 
stances a  compromise  may  be  made  by  adjusting  the  outer  blade  at  the  posterior 
extremity  of  an  oblique  diameter  of  the  pelvis,  and  over  a  lateral  angle  of  the  jaw. 

As  already  hinted  at  under  "  Perforation,"  the  great  principle  in  cranioclasis 
or  craniotraction  is  so  to  apply  the  instrument  and  so  to  make  traction  that  the 
normal  mechanism  of  labor  shall  be  imitated  as  closely  as  possible  In  othei 
words,  traction  should  be  made  so  that  the  portion  of  the  presenting  part  which  is 
naturally  lowest  tinder  normal  conditions  shall  be  kept  lowest  in  the  pelvis  and 
delivered  first,  as  in  spontaneous  delivery.  This  principle  is  often,  if  not  always, 
lost  sight  of;  and  because,  as  is  well  known,  a  firmer  hold  with  the  instrument  can 
be  secured  over  the  facial  bones,  or  over  the  side  of  the  skull  over  an  ear,  some 
operators  persist  in  using  only  these  two  localities,  with  an  entire  disregard  of 
the  mechanism  of  labor,  thus  giving  rise  10  serious,  and,  as  I  have  seen,  fatal  com- 
plications 


XVIII.   CEPHALOTRIPSY. 

Definition. — Cephalotripsy  is  the  crushing  of  the  presenting  part  by  an  in- 
strument resembling  the  obstetric  forceps.  In  1829  Baudelocque*  invented  an 
instrument  patterned  somewhat  after  the  obstetric  forceps,  which  he  designed  for 
crushing  the  fetal  head  by  grasping  it  in  the  same  manner  as  does  the  obstetric 
forceps,   and  without  previous  perforation  to  force  the  brain  from  the  mouth. 


Fig.   1 149. — Cephalotribe  Applied  at  the  Sides  of  the  Head.     Side  View. 


orbits,  and  nose,  crushing  the  cranial  bones  within  an  intact  scalp,  and  thus  pre- 
venting edges  of  fractured  bones  from  doing  injury  to  the  maternal  soft  parts. 
In  the  early  years  of  its  use  the  cephalotribe  was  intended  to  abolish  the  per- 
forator, the  craniotomy  (bone)  forceps,  and  the  crotchet.  The  cephalotribe  was 
originally  intended  only  to  crush  the  skull,  just  as  the  cranioclast  is  to-day  really 
an  instrument  designed  for  traction.  To-day  the  cephalotribe  is  used  both  as  a 
crusher  and  a  tractor. 

*A.  Baudelocque:   "  Revue  M6d.,"  August,  1S29,  p.  321. 


952 


OBSTETRIC  SURGERY. 


Indications. — All  forms  of  cephalotribe,  but  especially  the  broad-bladed  type, 
are  useful  to  compress  the  head  after  perforation  before  it  becomes  fixed  at  the 
brim.  As  a  tractor  after  perforation  in  the  lesser  degrees  of  obstructed  labor  it  is 
also  most  valuable.  A  limit  for  the  safe  employment  of  the  cephalotribe  exists, 
however — namely,  in  pelvic  contraction  when  the  clinical  index  of  the  pelvis  is 
represented  by  a  conjugata  vera  of  three  inches  the  safe 
limit  is  reached.  Much  depends,  moreover,  upon  the 
size  of  the  fetal  head  and  the  resiliency  of  the  cranial 
bones.  To-day  the  use  of  the  cephalotribe  is  mainly 
limited  to  a  crushing  of  the  head  or  breech  before  the 
application  of  the  cranioclast  for  purposes  of  traction, 
and  to  crushing  and  extracting  the  base  of  the  skull  in  the 
exceptional  cases  in  which  the  cranioclast  has  slipped  and 
torn  away  the  vault  of  the 
skull.  In  such  cases  the  ceph- 
alotribe is  most  useful  to 
secure  a  firm  hold  on  the  base 
of  the  skull,  to  crush  it,  and 
as  a  tractor  to  extract  the 
fetus.  Practically  this  is  the 
only  way  the  cephalotribe  is 
to-day  used  by  most  oper- 
ators. Some  operators  still 
follow  perforation  with  the 
application  of  the  cephalo- 
tribe as  a  crusher  and  an  ex- 
tractor, but  for  the  latter  pur- 
pose the  cranioclast  is  far 
superior. 

Cranioclast  and  Cephalo- 
tribe Compared. — (i)  The  cephalotribe  is  bulkier  and 
heavier  than  the  cranioclast  and  occupies  more  room 
in  the  pelvis  than  the  latter  instrument,  a  great  dis- 
advantage in  contracted  pelves.  (2)  Both  blades  of 
the  cephalotribe  lie  outside  the  fetal  skull,  and  unless 
the  narrow- bladed  instrument  is  used — and  this  is  very 
liable  to  slip — they  do  not  sink  into  the  scalp  as  does 
the  outer  blade  of  the  cranioclast.  On  the  other  hand, 
one  blade  of  the  cranioclast  is  hidden  in  the  cranial 
cavity  not  otherwise  occupied,  and  the  outer  fenes- 
trated blade  soon  sinks  into  the  scalp  and  thus  avoids 
injury  to  the  maternal  soft  parts.  Further,  after  a  short 
period  of  traction  with  the  cranioclast,  the  instrument, 
if  properly  applied,  comes  to  occupy  the  middle  of  the 
pelvis,  where  it  can  be  kept  with  the  left  hand  from 
contact  with  the  maternal  parts.  (3)  Traction  with 
the  cranioclast  as  the  head  is  being  drawn  through 
the  pelvis  exerts  an  even  pressure  on  all  points  of  the 
circumference  of  the  parturient  tract,  finally  elongat- 
ing the  fetal  head,  thus  diminishing  all  the  presenting  diameters  and  even  render- 
ing the  extraction  easier  as  traction  is  continued.  Extensive  lacerations  and  in- 
juries to  the  maternal  soft  parts  are  of  rare  occurrence  after  cranioclasis  and 


Fig.  1150.  —  Cephalo- 
tribe Applied  at  the 
Sides  of  the  Head. 
Anterior  View. 


Fig.  1151.  —  Breisky's 
Broad-bladed  Ceph- 
alotribe. 


CEPHALOTRIPSY. 


953 


craniotraction.  On  the  other  hand,  compression  of  the  head  with  the  cephalo- 
tribe  diminishes  only  one  diameter,  the  compressed  one,  and  correspondingly  in- 
creases the  opposite  ones — namely,  those  non-compressed  (Figs.  1149  and  1150). 
As  the  head  is  being  drawn  through  the  pelvis,  pressure  is  thus  concentrated  at 
two  points  of  the  parturient  tract  instead  of  being  diffused  over  the  entire  cir- 
cumference; thus  preventing  elongation  of  the  head  as  in  craniotraction,  and 
rendering  the  extraction  more  difficult  and  liable  to  injure  the  maternal  parts. 
(4)  As  a  rule,  the  cranioclast  takes  a  firmer  hold  of  the  fetal  head  than  does  the 
cephalotribe,  but  T  have  seen  many  exceptions. 

Instruments. — Practically  there  are  two  types  of  the  cephalotribe  in  use  to- 
day— namely,  the  narrow  or  solid-bladed,  and  the  broad  or  fenestrated-bladed  in- 
struments. Among  the  narrow  or  solid-bladed  instruments  are  Blot's  and  Scan- 
zoni's.  Among  the  broad  or  fenestrated-bladed  cephalotribes  are  Breisky's  (Fig. 
1 151)  and  its  many  modifications.  Olshausen's  cephalotribe  (Fig.  11 52)  is  an  ex- 
cellent example  of  the  narrow  solid-bladed  instrument,  and  Breisky's  of  the  broad 
fenestrated.  All  of  the  former  are  provided  with  a  generous  pelvic  curve,  but  the 
cephalic  curve  is  absent  in  some,  as  the  blades  are  in  close  apposition.  In  the 
latter  type  cf  instrument,  provision  is  made  for  both  a  pelvic  and  a  cephalic  curve: 


Fig. 


-Olshausen's  Narrow-bladed  Cephalotribe. 


the  pelvic  being  3^  inches  (8.2  cm.)  in  extent,  and  the  cephalic  2j  inches  (5.7 
cm.),  measured  from  the  outer  surfaces  of  the  blades.  A  serious  objection 
exists  to  each  type  of  cephalotribe,  neither  of  which  obtains  in  the  case  of 
the  cranioclast — namely,  the  narrow-bladed  cephalotribes,  whether  they  possess 
cephalic  carves  or  not,  are  liable  to  slip,  and  the  broad  type  occupies  too  much 
room  in  the  pelvis,  especially  when  the  latter  is  contracted. 

Operations. — The  principles  governing  the  application  of  the  cephalotribe  are 
precisely  the  same  as  in  the  case  of  forceps.  Following  perforation,  projecting 
spiculas  of  bone  must  be  carefully  extracted  with  the  fingers  or  dressing  forceps 
and  the  exact  presentation  and  position  again  determined. 

High  Cephalotribe  Operation  (Fig.  1153). — When  the  head  or  breech  is 
still  free  above  the  pelvic  inlet,  great  care  must  be  taken  to  have  the  presenting 
part  firmly  held  at  the  inlet  by  suprapubic  pressure  by  an  assistant.  Adap- 
tation of  the  cephalotribe  to  the  sides  of  the  fetal  head  at  the  pelvic  inlet  is  not 
safe,  or  in  fact  necessary.  Objection  has  been  raised  to  the  use  of  the  cephalo- 
tribe here,  that  seizing  the  head  antero-posteriorly  increases  the  transverse 
diameters  to  an  equal  extent,  and  that  this  would  be  particularly  disadvanta- 
geous,  especially  in  contracted  pelves  (Figs.   1149   and   11 50).     This  would  be 


954 


OBSTETRIC  SURGERY. 


Fig. 


1 153. — Broad-bladed  Cephalotribe  Applied  in  Ver- 
tex Presentation.     Median  Operation. 


true  were  the  head  fixed  transversely  in  the  pelvis,  but  when  the  head  is 
free  it  will  be  found  in  an  oblique  diameter,  and  the  cephalotribe  seizes 
the  bead  in  the  opposite  oblique  and  not  in  an  antero-posterior  diameter. 
Compensation  of  head  compression  thus  takes  place  in  an  oblique  diameter  op- 
posite to  the  one  grasped  by  the  instrument  and  not  in  a  transverse  diameter  of 
the  head.    Should,  by  chance,  the  head  be  seized  in  a  transverse  diameter,  rotation 

of  the  head  with  the 
cephalotribe  into  an  ob- 
lique diameter  can  read- 
ily be  accomplished. 
Dragging  of  a  head  or 
breech  through  the  pel- 
vic inlet  with  so  heavy 
and  powerful  an  instru- 
ment as  the  cephalo- 
tribe should  rarely  be 
attempted,  because  of 
the  danger  of  pressure 
of  the  blades  upon  the 
maternal  soft  parts  be- 
tween the  symphysis 
and  sacral  promontory. 
Should  antero-posterior 
adaptation  occur,  either 
spontaneously  or  arti- 
ficially, the  instrument 
must  be  removed  and 
reapplied  in  a  transverse 
or  an  oblique  diameter, 
or,  better,  the  cranio- 
clast  substituted.  Com- 
pression with  the  hand- 
screw  should  always  be 
slow,  and  repeated  digi- 
tal explorations  should 
be  made  to  detect  pro- 
jecting spiculae  of  bone. 
Low  Cephalotribe 
Operation.  —  The  left 
or  lower  blade  is  first  in- 
troduced at  the  extrem- 
ity of  the  transverse  or 
oblique  pelvic  diameter 
according  to  the  posi- 
tion of  the  presenting 
part,  followed  by  the  application  of  the  right  or  upper  blade;  great  care  being 
used  not  to  injure  the  uterine  or  vaginal  tissues.  As  in  high  operations,  com- 
pression is  made  slowly  with  the  hand-screw,  on  the  lookout  digitally  for  bone 
spiculae.  and  during  extraction  the  instrument  is  guided  and  the  maternal  parts 
are  protected  by  the  fingers  of  the  left  hand  (Figs.  1153  and  1155). 

Cephalotribe  to  the  Breech. — The  same  general  principles  apply  here  as  in 
head  presentations,  namely,  to  keep  the  instrument  in  an  oblique  or  transverse 
diameter  of  the  pelvis  (Fig.  1154). 


Fig.  1154. — Broad-bladed  Cephalotribe  Applied  to  the 
Breech. 


Fig.     1 155. — Narrow-bladed    Cephalotribe    Applied    to 
Vertex.     Low  Operation. 


DECAPITATION,  955 

After-coming  Head. — Although  some  authorities  (Lusk)  do  not  consider 
perforation  necessary  as  a  preliminary,  still  perforation  through  the  floor  and 
roof  of  the  mouth  before  the  application  of  the  instrument  will  be  found  to 
prevent  many  maternal  injuries. 

Decapitated  Head. — In  instances  of  detachment  of  the  fetal  head  from  the 
body  and  the  retention  of  the  former  in  the  uterine  cavity  the  cephalotribe  will 
often  prove  of  use  in  its  extraction.  The  head  must  be  steadied  at  the  inlet  with 
suprapubic  pressure  by  an  assistant,  and  I  prefer  to  grasp  the  scalp  or  face  from 
below  with  a  strong  volsella  forceps  as  well,  and  then  apply  the  cephalotribe  to 
crush  and  extract. 

Substitutes  for  Cranioclasis  and  Cephalotripsy. — Although  great  ingenuity  has 
been  exerted  to  invent  other  and  more  satisfactory  substitutes  for  the  operations 
of  cranioclasis  and  cephalotripsy,  still  in  spite  of  the  shortcomings  and  defective- 
ness of  these  latter  measures  for  diminishing  the  size  of  the  fetal  head  and  breech, 
most  obstetric  surgeons  are  agreed  that  these  operations  are  at  the  present 
time  the  best  we  have  at  our  command.  Craniotomy:  This  was  the  original 
and  now  practically  obsolete  method  of  diminishing  the  size  of  the  fetal  skull, 
and  brought  into  use  various  forms  of  craniotomy  forceps.  After  perforation  and 
removal  of  the  brain,  one  of  these  bone  forceps  was  introduced  under  the  scalp 
and  the  parietal,  occipital,  and  frontal  bones  were  seized  and  broken  away  piece- 
meal by  a  twisting  movement  of  the  wrist.  The  operation  was  tedious  and  dan- 
gerous, for  unless  the  maternal  soft  parts  were  carefully  guarded  the  withdrawal 
of  the  sharp  fractured  bones  caused  dangerous  lacerations.  The  craniotomy  for- 
ceps of  Meigs  and  Taylor,  which  were  nothing  more  than  heavy  bone  forceps, 
were  at  one  time  generally  used  in  this  country.  Inquiry  of  the  largest  instru- 
ment-makers in  New  York  city  shows  that  the  demand  for  craniotomy  forceps 
has  practically  ceased.  Cephalotomy:  It  has  been  proposed  either  to  remove 
the  fetal  head  in  segments  or  to  divide  the  skull  into  two  halves.  The  forceps  saw 
of  Van  Huevel  was  intended  to  divide  the  head  from  vertex  to  base  into  two 
halves*  to  remove  from  the  head  a  triangular  segment  the  apex  of  which  should 
include  the  bones  at  the  base  of  the  skull.  The  wire  6craseur  has  been  applied  to 
successive  portions  of  the  head  for  the  purpose  of  crushing,  as  suggested  by 
Barnes,  of  London. f  Hubert  invented  a  transforateur  which  was  intended  to 
bore  through  and  break  up  the  sphenoid  bone,  and  thus  diminish  the  resistance  of 
the  base  of  the  skull.  Instruments  which  combined  the  principles  of  the  trans- 
forateur and  the  cephalotribe  were  invented  by  Valette,  Huter,  and  Solline,  and 
were  termed  'sphenotribes."  To-day  I  know  of  no  operation  of  cephalotomy  that 
for  effectiveness  and  safety  can  successfully  compete  with  cranioclasis.  The 
mechanical  principles  involved  in  many  of  the  proposed  cephalotomy  procedures 
are  in  the  main  correct,  but  the  instruments  are  complicated,  and  some  of  them 
are  too  bulky  to  be  used  with  advantage  in  cases  of  pelvic  contraction. 


XIX.    DECAPITATION. 

Definition. — A  separation  within  the  uterus  of  the  fetal  head  from  its  trunk. 

Indications. — Infrequently  in  neglected  impacted  shoulder  presentations 
division  of  the  fetal  head  from  the  body  is  demanded  in  order  to  break  up  the 
triangular  wedge  which  blocks  the  pelvis;  dividing,  so  to  speak,  the  wedge  in  two 

*  "  Diet,  de  Medecine  et  de 'Chirugie,"  Art.  "  Embryotomie,"  page  6So. 
t  "Obstetric  Operations,"  page  411. 


956 


OBSTETRIC  SURGERY. 


f%. 


parts,  thus  permitting  the  delivery  first  of  the  fetal  body  and  subsequently  of 
the  head.     The  indications  are  thus  almost  exclusively  in  neglected  impacted 

shoulder  presentation,  in  which  at- 
tempts at  any  form  of  version  to 
correct  the  malpresentation  would 
jeopardize  the  already  dangerously 
thinned  lower  uterine  segment.  The 
pelvis  must  have  a  true  conjugate  of 
at  least  zf  inches  (nearly  7  cm.),  and 
full  dilatation  of  the  cervix  must  be 
present  or  secured  artificially. 

Operation. — Various  forms  of  de- 
capitators  are  in  use,  ranging  from  a 
simple  whip-cord  decapitator  to  most 
complicated  and  expensive  embryo- 
tomes  made  up  of  many  parts.  All 
types  of  decapitators  may  be  in- 
cluded among  the  following:  (i)  Karl 
Braun's  blunt  hook;  (2)  Schultze's 
sickle  hook;  (3)  scissors;  (4)  the  wire 
ecraseur;  (5)  various  embryotomes, 
notably  those  of  Pierre  Thomas  and 
M.  Tarnier;  (6)  the  chain-saw;  (7)  the 
whip-cord.  In  default  of  special  in- 
struments, a  wire  or  a  strong  cord  may 
be  passed  around  the  fetal  neck  by 
means  of  an  English  catheter  or  per- 
forated blunt  hook,  and  by  a  sawing 
motion  the  neck  may  be  divided  The 
chain-saw  of  the  surgeons  may  be 
adapted  to  the  same  purpose.  Much 
difficulty  is  often  encountered  in  pass- 
ing the  cord,  chain-saw,  or  wire  of  an 
ecraseur  over  the  neck,  and  ingenious 
and  complicated  instruments  have  been  invented  to  overcome  the  difficulty. 
The  simplest  method  is  to  thread  a  piece  of  bobbin  two  feet  long  into  the  end 
of  a  No.  16  English  catheter  with  stylet  in  place  (Fig.  1109).     A  curve  is  next 


Fig.  1 156. — Braun's 
d  e  c a  p itati n  g 
Hook. 


Fig.  1157. — Decapi- 
tating Sickle 
Knife    of     Rams- 

BOTHAM. 


Fig.    T158. — Dubois's   Decapitating  and  General  Embryotomy  Scissors. 


imparted  to  the  catheter  by  placing  it  in  warm  water  if  necessary,  and  it  is  then 
passed  around  the  fetal  neck.     An  end  of  the  bobbin  is  caught  with  two  fingers 


DECAPITATION. 


967 


-^rfr<«^^*9*._. 


in  the  vagina  or  with  dressing  forceps,  and  the  catheter  is  finally  withdrawn  with 
the  other  end.  The  bobbin  encircling  the  neck  is  used  to  drag  up  and  around  a 
whip-cord  or  the  wire  or  chain  of  an  dcraseur.  In  the  use  of  cord,  wire,  or  chain 
great  care  must  be  used  to  protect  the  maternal  soft  parts,  and  to  make  sure  that 
a  portion  of  the  cervix  is  not  included  in  the  instrument  used.  The  choice  of 
instruments  to-day  usually  lies  between  (i)  Braun's  blunt  hook  decollator  (Fig. 
1 156);  (2)  a  stout  pair  of  scissors,  as  Dubois's  (Fig.  1158);  (3)  a  curved  knife- 
edge  hook,  as  Schultze's  or  Ramsbotham's  (Fig.  1157).  Perhaps  nowhere  more 
than  in  obstetrics  does  tradition  influence  one  in  the  choice  of  instruments  and 
operative  procedure.  For  this  reason  the  blunt  decapitating  hook  of  Braun  is 
described  and  recommended  by  each  obstetric  writer  in  turn.  After  many  un- 
prejudiced comparisons  of  the  Braun  hook  with  a  strong  pair  of  scissors  and  the 
knife-edge  hook,  I  am  unable  to 
understand  why  one  should  prefer 
such  an  awkward  and  unscientific 
instrument  as  the  first  to  either  of 

the  latter.     My  choice  of    instru-  ,      \  ~ 

ments  is  for  the  scissors  and  sickle 
knife.  I  rarely  if  ever  use  a  Braun's 
hook,  except  occasionally  for 
demonstration.  The  space  occu- 
pied by  each  of  the  three  instru- 
ments in  a  narrow  pelvis  is  about 
the  same,  the  choice,  if  any,  being 
in  favor  of  the  scissors. 

I.  Braun's  Blunt  Hook  De- 
collator (Figs.  1 156  and  11 59). — 
This  instrument  is  a  modified  blunt 
hook  with  its  end  bent  nearly  at  an 
acute  angle,  flattened  somewhat 
from  side  to  side,  and  terminating 
in  a  blunt  button  shaped  like  the 
end  of  a  foil.  The  handle,  formerly 
of  ebony  but  now  cast  in  one  piece 
with  the  rest  of  the  instrument,  is 
set  at  right  angles,  thus  imparting 
when  grasped  with  the  whole  hand 
a  powerful  leverage  movement  to 
the  hooked  end.  Operation:  Every 
instrument  should    be  thoroughly 

tested  upon  a  piece  of  soft  wood,  such  as  pine  kindling,  before  being  put  into 
use,  to  avoid  an  unexpected  break  and  to  guard  against  injury  to  the  soft  parts 
of  the  mother.  Decapitation  is  usually  performed  in  shoulder  presentation,  and 
although,  so  far  as  I  am  aware,  no  text-book  mentions  the  fact,  still  I  have  found 
in  practice  that  there  is  a  distinct  choice  of  hands  to  be  iised  in  left  and  right 
shoulder  positions.  In  all  cases  if  an  arm  is  prolapsed,  it  is  advisable  to  apply 
a  sling  to  it  and  have  an  assistant  make  firm  traction  on  it  to  fix  the  shoulder 
firmly  in  the  pelvic  inlet.  In  left  shoulder  positions  it  is  advisable,  if  the  operator 
has  sufficient  control  over  his  left  hand,  to  encircle  the  fetal  neck  with  the  fingers 
of  the  right  hand,  the  thumb  to  the  front  of  the  neck,  namely,  in  the  anterior  por- 
tion of  the  pelvic  inlet,  in  both  anterior  and  posterior  right  shoulder  positions,  and 
index  and  other  fingers  behind.      The  neck  is  then  grasped  firmly  and  with  the  aid 


Fig. 


1 159. — Method    of    Decapitating 
Braun's  Decapitating  Hook. 


958 


OBSTETRIC  SURGERY. 


of  the  prolapsed  arm  drawn  down  as  far  as  possible  into  the  pelvis.  The  hook  of 
the  decollator  is  next  carefully  passed  with  the  left  hand  behind  the  symphysis, 
along  the  right  thumb  of  the  operator  as  a  guide,  and  the  button  end  of  the  hook 
passed  over  the  neck  and  received  by  the  right  index  finger  at  the  other  side  of 
the  neck  and  in  the  rear  of  the  pelvis.  The  handle  of  the  instrument  is  now 
seized  with  the  left  hand  and  by  a  rotary  motion  of  the  instrument  between  the 
index  finger  behind  and  the  thumb  in  front,  thus  guarding  the  point  at  all  times 
as  far  as  possible,  the  neck  tissues,  portion  by  portion,  are  seized  by  the  button 
point  and  twisted  off  until  the  spinal  column  is  divided  with  the  same  rotary- 
motion  or  by  direct  downward  traction  on  the  remaining  soft  tissues  of  the  neck. 
Separation  of  these  last  tissues  by  twisting  and  downward  traction  must  not  be 

too  sudden,  lest  the  sudden  freeing 
of  the  hook  penetrate  the  maternal 
soft  parts.  This  accident  may  be 
avoided  by  care  in  the  use  of  the 
hook  or  by  substituting  a  pair  of 
scissors  or  a  sickle  knife  to  divide 
the  last  few  shreds  of  tissue.  In 
right  shoulder  positions  I  have 
found  it  most  convenient  to  reverse 
the  position  of  the  two  hands  of  the 
operator,  using  the  left  hand  to  en- 
circle the  neck  and  the  right  to  ro- 
tate the  instrument.  This  is  the 
usual  position  of  the  shoulder  illus- 
trated in  the  text-books,  whereas 
the  left  scapulo-anterior  is  the  most 
common,  and  the  use  of  the  oper- 
ator's hands  in  this  position  is  thus 
left  to  the  imagination. 

2.  Sickle-Knife  or  Curved- 
Saw  Decapitators. — A  more  con- 
venient and  safer  mode  of  decapita- 
tion, even  for  the  experienced  oper- 
ator, is  a  sickle  knife  (Figs.  1157, 
1 160,  and  1 161),  or  a  decapitating 
hook  with  serrated  edge.  I  am  ac- 
customed to  use  the  scissors  in  con- 
junction with  one  of  these  instru- 
ments to  the  exclusion  of  the  un- 
scientific and  awkward  Braun's 
hook.  Operation:  Each  instrument  should  be  carefully  tested  before  use.  The 
shoulder  should  be  brought  as  low  in  the  pelvic  inlet  as  possible  by  traction  with 
a  sling  upon  a  prolapsed  arm.  In  left  shoulder  positions  we  encircle  the  neck 
with  the  right  hand  and  with  the  left  carry  the  decapitator  up  in  front  of  the  neck, 
the  point  being  directly  toward  the  head  when  the  level  of  the  neck  is  reached, 
pass  the  point  over  the  neck  and  palpate  behind  with  the  internal  or  right  fingers 
to  make  sure  that  the  instrument  is  properly  adjusted  over  the  fetal  neck.  The 
point  being  guarded  with  the  internal  hand,  the  decapitator  is  now  drawn  firmly 
downward  and  with  a  to-and-fro  movement,  as  far  as  the  vaginal  outlet  will  per- 
mit, the  neck  is  quickly  cut  through  (Fig.  1161).  A  common  mistake  with  the 
novice  is,  after  the  vertebrae  are  divided,  to  incline  the  plane  of  section  into  the 


Fig.  1 160. — Method  of  Decapitating  with  De- 
capitating Sickle  Knife  of  Ramsbotham. 


DECAPITATION. 


959 


fetal  body  or  shoulder  instead  of  cutting  through  the  remainder  of  the  neck.  Re- 
peated palpation  with  the  internal  hand  will  prevent  this  error,  which  unneces- 
sarily prolongs  the  operation.  The  last  shreds  of  cervical  tissue  should  not  be  too 
suddenly  divided  lest  the  sudden  release  of  the  decapitator  lacerate  the  maternal 
soft  parts.  In  right  scapulo-positions  the  left  fingers  encircle  the  neck  and  the 
decapitator  is  used  in  the  right  hand  outside  of  the  vulva.  In  both  right  and 
left  positions  the  point  of  the  sickle  knife  or  curved  saw  decapitator  should  be 
pointed  to  the  posterior  part  of  the  pelvis  to  avoid  injury  to  the  bladder,  and 
the  handle  during  the  pendulatory  movement  inclined  as  far  forward  as  possible. 
We  thus,  by  cutting  downward  and  forward,  avoid  injuring  the  rectum. 

3.  Decapitation  with  Blunt  Scissors  (Figs.  1158,  1162). — Although  the 
objection  has  been  raised  to  the  scissors  decapitator  that  it  is  apt  to  wound  the 
maternal  soft  parts  or  the  operator's  fingers,  yet  this  method  after  a  little  practice 


Fig     1161. — Method    of    Holding   the 
Sickle-knife  Decapitator. 


Fig.   1 162. — Decapitating    with  Scissors. 


on  the  manikin  will  usually  prove  a  safe  and  rapid  one  and  will  be  selected  in  pref- 
erence to  the  Braun  hook  or  curved  knife  or  saw  methods.  Operation:  The  arm 
is  prolapsed  as  in  the  first  two  methods,  and  the  choice  of  hands  is  the  same.  The 
cutting  should  be  done  from  below  upward,  the  outer  surface  of  the  blunt  points 
being  guided  with  the  internal  finger.  Some  difficulty  may  be  experienced  in 
dividing  the  last  few  shreds  of  tissue  at  the  upper  part  of  the  neck,  and  this  can  be 
overcome  by  hooking  the  index-finger  over  the  string  of  tissue,  drawing  it  down 
into  the  vagina,  and  cutting  along  the  finger  as  a  director.  All  the  decapitating 
scissors  have  a  common  fault,  namely,  the  handles  are  too  small,  admitting  only 
one  finger  into  each.  In  active  use  these  fingers  become  bruised  and  numb  bv 
reason  of  the  severe  pressure  to  which  they  are  subjected.  To  overcome  this 
objection  I  have  had  made  both  a  straight  and  a  curved  pair  of  obstetric  scis- 
sors with  handles   to  admit   several    fingers.     These  scissors  are   powerful   and 


960  OBSTETRIC  SURGERY. 

convenient,  and  serve  equally  well  for  decapitation,  eventration,  amputations  of 
extremities,  or  spondylotomy. 

Extraction  after  Decapitation. — Toward  the  end  of  the  operation  the  fetal 
head  should  be  fixed  at  the  pelvic  inlet  by  suprapubic  pressure  by  an  assistant 
(Fig.  1 1 67).     The  obstructing  wedge  should  be  broken  up  by  the  complete  sever- 
ing of  the  neck,  when  the  fetal  body 
may  be  readily  delivered  by  traction 
upon  the  prolapsed  arm.     The  head 
X  may  possibly   be   delivered    sponta- 

''■'.-,  neously;  it  is  best,  however,  not  to 

wait  for  uncertainty,  but  to  pass  the 
hand  up  and  manually  deliver  at  once. 
:  ( I )  The  stump  of  the  vertebral  column 

--_   ,,  should  be  palpated  for  sharp  project- 

^*"'--  ing  vertebrse,  and  if,  as  usually  hap- 

pens, none  are  present,  two  fingers  are 
"^V^  passed  into  the  mouth  and  the  thumb 

over  the  base  of  the  skull  for  counter- 

,>--     "^  pressure  and    the  head   is  delivered 

-^itP^    J  manually  in  a  face  presentation  (Fig. 

\  ^^   ^  1163).     (2)  If  much  resistance  is  met 

"-"""""^   -"'i*^'''*^  with,  the  blunt  hook  or  a  crotchet,  if 

Fig.    1 163.— Manual   Extraction   of    the       one  is  at  hand,  may  be  substituted  for 
Decapitated  Head.  .-l.      r-  •      ,  1  ,1         /    \    rr 

the  fingers  m  the  mouth.      (3)  If  a 

sharp  projecting  vertebral  stump  ex- 
ists, extraction  in  face  presentation  may  dangerously  lacerate  the  maternal  soft 
parts.  It  is  then  better  either  to  extract  the  head  vertex  first  with  the  forceps,  or 
to  perforate  the  vertex  and  extract  with  a  cranioclast  (Fig.  1148),  or  with  two 
fingers  wrapped  with  aseptic  gauze  and  passed  into  the  opening  in  the  skull,  and 
the  thumb  over  the  occipital  bone  for  counter-pressure.  The  gauze  is  to  protect 
the  fingers  from  laceration  by  the  cranial  bones.  (4)  In  contracted  pelves,  per- 
foration and  extraction  with  the  cranioclast  or  cephalotribe  should  be  the  method 
of  election  (Fig.  1148) 


XX.  EXENTERATION  OR  EVISCERATION. 

By  this  is  meant  the  opening  of  the  thorax  or  abdomen,  or  of  both,  and  the 
removal  of  their  contents. 

Indications. — The  most  common  indication  is  in  case  of  shoulder  presentation 
in  which  decapitation  fails  or  is  impossible,  especially  when  the  head  and  neck  are 
so  high  above  the  pelvic  inlet  as  to  be  difficult  to  reach.  Evisceration  is  occasion- 
ally demanded  in  cases  of  monsters  after  perforation,  extraction  of  the  head, 
and  cleidotomy,  and  of  fetal  tumors,  as  cystic  kidney,  ascites,  or  distended 
bladder. 

Operations. — The  opening  into  the  abdomen  or  thorax  can  be  made  with  any 
of  the  perforators,  or  with  a  straight  or  curved  pair  of  Dubois  scissors,  whichever 
is  most  convenient.  No  matter  what  instrument  is  used,  the  maternal  parts 
must  be  carefully  guarded  from  injury ;  and  if  the  part  to  be  perforated  is  at  all 
movable,  it  should  be  firmly  grasped  with  stout  volsella  forceps  and  fixed  at  the 
inlet  by  suprapubic  pressure.     When  the  chest  is  entered,  it  is  advisable  to  secure 


AMPUTATION   OF  EXTREMITIES— CLEWOTOMY,  961 

an  ample  and  permanent  opening  either  by  enlarging  the  original  opening  made 
with  the  perforator  by  turning  the  instrument  so  as  to  make  a  second  incision  at 
right  angles  to  the  first,  or,  better  still,  by  cutting  away  several  segments  of  ribs 
with  the  heavy  Dubois  scissors.  The  viscera  are  removed  with  strong  volsella 
forceps,  first  breaking  them  up,  if  necessary,  with  the  perforator  or  scissors.  In 
shoulder  presentation  the  abdominal  cavity  may  be  reached  directly  from  the 
thorax  by  perforating  the  diaphragm,  and,  again,  in  difficult  breech  extractions 
the  thorax  can  be  opened  from  the  abdomen  by  the  same  route.  After  eviscera- 
tion in  impacted  shoulder  presentation  the  simplest  method  of  delivery  should  be 
chosen,  (i)  Usually  the  reduced  bulk  of  the  fetus  renders  it  easy  and  safe  to 
pass  up  the  appropriate  hand,  seize  the  feet  or  head,  and  do  an  ordinary  podalic 
version  without  injury  to  the  distended  uterine  segment  or  cervix,  thus  imitating 
nature's  method  of  spontaneous  version.  (2)  Should  difficulty  be  experienced,  a 
further  operation  of  disjointing  the  spine  with  the  Dubois  scissors  in  the  dorsal 
region  may  be  performed,  and,  the  fetus  being  divided  in  halves,  each  half  is 
separately  delivered.  (3)  In  cases  of  macerated  or  small  fetuses  it  will  not  be 
necessary  to  divide  the  spine,  but  with  a  blunt  hook  the  fetus  may  be  doubled 
upon  itself  and  delivered  in  imitation  of  nature's  method  in  spontaneous  evolu- 
tion. This  method  of  delivery  is  facilitated  by  prolapse  of  an  arm,  for  then 
traction  can  be  made  upon  both  blunt  hook  and  prolapsed  arm  at  one  and  the 
same  time.  Extraction  after  mutilation  of  the  fetal  soft  parts  requires  no 
special  technique,  as  the  reduction  in  size  is  supposed  to  be  so  thorough  that 
general  principles  will  suffice. 


XXI.  AMPUTATION  OF  EXTREMITIES. 

Only  rarely  is  the  obstetrician  called  upon  to  amputate  an  extremity  or 
several  extremities.  Possibly  it  may  be  demanded  in  cases  of  fetal  monstrosities 
and  impaction  of  multiple  presentations  (page  558).  The  amputation  is  best 
performed  with  the  curved  obstetric  scissors. 


XXII.  CLEIDOTOMY. 

Cleidotomy  or  division  of  both  clavicles  is  an  obstetric  operation  which  has  for 
its  object  the  diminution  of  the  bisacromial  diameter  of  the  dead  fetus,  when  the 
shoulders  obstruct  its  passage.  This  simple  operation,  rarely  mentioned  in  the 
text-books,  has  never,  I  believe,  taken  its  proper  place  in  obstetric  surgery,  as  a 
means  of  lessening  maternal  morbidity  and  mortality.  How  often  we  hear  of  in- 
stances in  which,  after  perforation  and  extraction  of  the  fetal  head  in  the  case  of  a 
generally  contracted  pelvis  or  outlet,  or  an  excessively  large  child,  twenty  minutes 
or  more  were  spent  in  extraction  of  first  one  and  then  the  other  shoulder,  thereby 
adding  perhaps  to  the  already  existing  shock!  As  a  matter  of  routine  in  these 
cases  I  am  accustomed  to  divide  the  clavicles,  and  it  is  amazing  how  the  diminu- 
tion of  the  bisacromial  diameter  thus  produced  renders  the  subsequent  extrac- 
tion of  the  fetal  shoulders  a  comparatively  easy  task.  In  a  number  of  instances 
at  the  Emergency  Hospital,  in  which  birth  of  the  head  had  been  accomplished  by 
forceps  or  perforation  and  craniotraction,  the  shoulders  resisting  all  ordinary 
methods  of  extraction,  the  simple  operation  of  cleidotomy  completely  changed  the 
clinical  picture.  From  measurements  taken  at  the  bedside,  and  from  experi- 
-     61 


962 


OBSTETRIC  SURGERY. 


ments  upon  fetal  cadavers,  I  have  found  that  the  bisacromial  diameter  is  in 
cleidotomy  readily  reduced  from  5  inches  (12.7  cm.)  to  3^  inches  (8.89  cm.). 
Figs.  1 165  and  1166  show  a  fetal  cadaver,  photographed  on  the  same  scale 
before  and  after  cleidotomv. 


Fig.  1164. — The  Oper.^tion  of  Cleidotomy,  Performed  with  Long  Curved  Scissors. 


V 


-41 /n.. 


Fig.  1165. — Fetal  Cadaver  before  Clei- 
dotomy. 


Fig.  1 166. 


-Fetal  Cadaver  after  Clei- 
dotomy. 


Operation. — This  is  best  performed  with  the  curved  obstetric  scissors  (Fig. 
1 1 58),  two  fingers  of  the  left  hand  being  used  to  guide  the  blunt  points  to  the 
middle  of  each  clavicle.  It  will  usually  be  necessary  to  extend  or  fiex  laterally 
the  fetal  head  strongly  so  as  to  give  room  for  the  use  of  the  scissors.      (Fig.  1 164.) 


EXPRESSION   OF   THE   FETUS. 


963 


XXIII.  SPONDYLOTOMY. 

spondylotomy  is  an  operation  for  dividing  the  spinal  column  of  the  fetus  very 
much  as  it  is  divided  in  decapitation,  and  has  been  recommended  *  as  an  alter- 
native for  the  latter  operation.  The  operation  as  well  as  the  subsequent  extrac- 
tion requires  more  time  and  is  more  difficult  than  decapitation. 


(C)    OPERATIONS    FOR   DELIVERY. 

I.   EXPRESSION  OF  THE  FETUS.     EXPRESSIO  FOETUS. 

(Fig.  1 167.) 

Definition. — Expression  of  the  fetus  is  the  term  applied  to  the  method  of  de- 
livery of  the  child  by  the  exertion  of  pressure  upon  the  fundus  of  the  uterus.     It 


Fig.  1 167. — Expression  of  the  Fetus.      Expressio  Fcetus. — (From  a  photograph  taken 

at  the  Emergency  Hospital.) 


acts  by  increasing  the  intra-abdominal  pressure  and  stimulating  the  uterine 
muscle  to  contraction.  In  one  form  or  another  this  principle  has  been  employed 
from  the  earliest  times  by  people  of  all  nations,  civilized  and  barbarous. 

*  Professor  A.  R.  Simpson,  of  Edinburgh. 


964  OBSTETRIC  SURGERY. 

Indications. — Some  hold  that  this  method  may  complete  delivery  in  the  en- 
tire absence  of  pains,  but  it  is  usually  adopted  only  as  a  means  of  increasing  the 
duration  and  strength  of  the  normal  uterine  contractions.  In  this  way  it  is  used 
at  the  end  of  the  second  stage  when  the  uterine  contractions  lack  force  and  the 
external  genitals  are  not  too  tense  and  narrow.  With  a  small  fetus  it  may  be  of 
great  value  when  there  is  an  indication  for  immediate  delivery.  In  such  a  case 
expression  may  complete  the  expulsion  of  the  fetus  more  rapidly  than  any  other 
procedure.  When  pains  have  been  weakened  by  anesthesia  and  the  fetus  is  in 
danger  it  is  of  value.  A  further  indication  results  from  failure  of  the  head  to  en- 
gage in  the  brim  of  the  pelvis,  although  the  uterus  is  contracting  strongly  and  no 
disproportion  between  the  size  of  the  head  and  that  of  the  inlet  exists.  Such 
a  condition  is  present  when  a  pendulous  abdomen  permits  a  marked  anteversion 
or  anteflexion  of  the  uterus.  The  same  result  may  occur  from  the  presence  of  a 
maternal  umbilical  or  ventral  hernia.  Under  these  circumstances  properly  ap- 
plied pressure  upon  the  abdominal  wall  will  cause  the  head  to  enter  the  brim  and, 
assisted  by  the  natural  expulsive  force  of  the  uterus,  it  will  advance  rapidly.  In 
delivery  of  the  second  twin,  expression  is  sometimes  of  assistance,  but  great  care 
must  be  exercised  that  the  uterus  is  not  emptied  too  suddenly. 

Contraindications. — The  presence  of  a  large  amount  of  fat  in  the  abdominal 
wall  interferes  seriously  with  the  manoeuver.  Marked  tenderness  and  tonic  con- 
traction of  the  uterus  are  absolute  contraindications.  If  inflammatory  con- 
ditions of  the  adnexa  are  present,  external  pressure  may  lead  to  dangerous  re- 
sults. Disproportion  between  the  size  of  the  fetus  and  of  the  parturient  canal, 
whether  from  narrowing  of  the  pelvis  or  rigidity  of  the  soft  parts  or  other  cause, 
should  prevent  its  employment. 

Operation. — The  woman  is  placed  in  the  dorsal  position,  close  to  the  edge  of 
the  bed  or  upon  a  table.  Anesthesia  is  of  value  in  some  cases,  but  in  others  it  is 
not  desirable,  as  it  diminishes  the  natural  uterine  contractions.  The  operator, 
standing  at  the  right  side,  grasps  the  fundus  between  the  two  hands  and  exerts 
pressure  upon  the  uterus  in  the  axis  of  the  inlet  (Fig.  1167).  This  is  done  only 
during  the  uterine  contractions,  beginning  gently  and  gradually  increasing  the 
amount  of  force  employed.  During  the  interval  between  the  pains  the  uterus 
may  be  gently  massaged.  Care  must,  of  course,  be  exercised,  as  in  the  Cred^ 
method  of  placental  expulsion,  that  no  injury  is  done  to  the  appendages  by  the 
use  of  undue  force  improperly  applied.  Even  when  the  method  is  adopted  in 
cases  in  which  there  are  no  natural  uterine  contractions,  intermittent  pressure 
alone  should  be  used,  imitating,  as  far  as  possible,  the  normal  labor  pains. 


II.  FORCIBLE  DELIVERY.     ACCOUCHEMENT  FORCE. 

Definition. — By  accouchement  force  we  understand  three  operations:  viz.,  (1) 
the  complete  rapid  instrumental  or  manual  dilatation  of  the  cervical  canal;  fol- 
lowed (2)  by  either  combined  or  internal  version  or  the  application  of  the  for- 
ceps; and  (3)  the  immediate  extraction  of  the  child.  The  accouchement  forc^ 
of  the  old  writers  upon  obstetrics  was  often  quite  another  and  more  serious 
operation,  for  the  condition  of  the  cervical  canal  was  frequently  lost  sight  of 
and  the  operation  too  frequently  meant,  (i)  the  plunging  of  the  hand  or  the 
application  of  the  forceps  through  a  cervical  canal  imperfectly  dilated  or  torn 
by  the  insertion  of  the  hand,  and  (2)  the  immediate  extraction  of  the  fetus 
through  this  constricted  or  lacerated  os.  That  the  latter  definition  of  the  term 
still  obtains  is  proved  by  the  accidents  that  are  constantly  occurring  during  the 
extraction  of  the  fetus. 


FORCIBLE  DELIVERY. 


965 


Indications. — In  the  event  of  placenta  prasvia  when  the  hemorrhage  has  been 
temporarily  arrested  and  there  is  necessity  for  immediate  evacuation  of  the 
uterine  contents,  there  is  probably  presented  the  most  urgent  indication  for  the 
performance  of  this  operation.  In  case  of  the  sudden  death  of  the  mother  this 
procedure  is  indicated  only  when  there  is  hope  of  delivering  the  child  more 
quickly  by  this  method  (see  Post-mortem  Delivery,  page  669).  In  cases  of 
eclampsia  when  other  means  fail  and   it  is  necessan.^  to  empty  the  uterus,  this 


Fig.  1 168. — Dangers  of  a 
Rapid  Breech  Extraction 
through  an  imperfectly 
Dilated  Os.  The  external  os 
is  not  fully  dilated  or  is  para- 
lyzed. Traction  on  the  legs 
results  in  extension  of  the 
head  and  arms. 


Fig.  1169. — ^Manual  Extraction  of  the  Fore-com- 
iNG  Head  by  the  Introduction  of  Two  Fingers 
into  the  Rectum.     Ritgen's  Method. 


method  may  be  indicated,  as  rapidity  is  required,  since  convulsions  are  more 
likely  to  occur  as  long  as  manipulation  of  the  uterus  continues. 

Dangers. — Unless  performed  in  the  most  rapid  and  scientific  manner,  this 
operation  is  full  of  danger,  being  attended  by  a  high  percentage  of  maternal 
mortality.  It  is  apt  to  be  very  destructive  to  the  tissues  of  the  uterus.  In 
placenta  prasvia  the  danger  of  uterine  rupture  and  infection  is  a  contraindica- 
tion to  this  procedure. 

Operation. — (See  ]\Ianual  Dilatation  of  Cervix,  page  895,  and  Version,  page 
919,  also  Breech  Extraction,  page  968.) 


III.   MANUAL  EXTRACTION  OF  THE  FORE-COMING  HEAD. 
RITGEN'S  METHOD  (Fig.  1169). 

Definition. — The  digital  extraction  of  the  head  in  head-first  delivery  at  the 
end  of  the  second  stage  by  the  introduction  of  two  fingers  into  the  rectum  of 
the  mother,  favoring  extension  of  the  head,  in  vertex  presentation,  through 


966  OBSTETRIC  SURGERY 

the  vulval  orifice.  The  operation  is  often  combined  with  that  of  expressio 
foetus. 

Indication. — Tedious  or  powerless  labor  at  the  end  of  the  second  stage;  when 
the  relative  indication  for  the  forceps  exists  at  this  time  and  no  instrument  is  avail- 
able. It  may  also  be  employed  when  the  pains  are  so  severe  that  control  of  the 
head  is  impossible.  In  this  case  an  anesthetic  is  given  and  the  head  is  extracted 
in  the  interval  between  contractions. 

Dangers. — Injury  of  the  rectal  mucous  membrane  of  the  mother  or  of  the  eyes 
of  the  fetus  is  liable  to  result  from  too  vigorous  or  carelessly  applied  pressure.  I 
have  seen  severe  venous  hemorrhage.     The  operation  is  not  aseptic. 

Operation. — Anesthesia  is  not  necessary,  but  in  great  rigidity  of  the  part  its 
use  is  desirable,  especially  in  primiparas.  Two  fingers  of  the  right  hand  are  intro- 
duced into  the  rectum  and  continued  pressure  is  brought  to  bear  in  vertex  presen- 
tation upon  the  forehead,  the  malar  prominences,  the  superior  maxilla,  or  the 
chin,  thus  gradually  extending  the  head  through  the  ostium  vaginas.  Great  care 
must  be  taken  to  avoid, pressure  upon  the  eyes.  Similar  procedures  are  advo- 
cated by  others,  viz.,  combining  pressure  upon  the  face  of  the  fetus  by  one  or  two 
fingers  in  the  rectum  with  restraint  of  the  head  during  its  advance  by  pressure 
applied  to  the  exposed  portion  of  the  vertex.  The  aim  of  all  is  to  advance  the 
head  gradually,  in  the  absence  of  uterine  contractions  or  in  the  intervals  between 
pains,  under  anesthesia  in  cases  in  which  the  contractions  are  so  severe  and  fre- 
quent that  protection  of  the  perineum  is  impossible  without  an  anesthetic.  It  is 
preferable  to  avoid  the  lack  of  asepsis  involved  in  this  operation  by  using  a  suffi- 
cient amount  of  pressure  upon  the  fundus  to  enable  the  middle  finger  of  the  right 
hand  to  obtain  a  point  of  pressure  upon  the  forehead  of  the  fetus  by  reaching 
behind  the  anus,  without  entering  the  rectum.  (Compare  Perineal  Protection, 
page  480  and  Fig.  616  ) 


IV.  SHOULDER  EXTRACTION  IN  HEAD-FIRST  CASES. 

After  the  birth  of  the  head  there  sometimes  occurs  delay  in  delivery  of  the 
shoulders,  which  may  result  in  the  death  of  the  fetus  from  prolonged  pressure 
upon  the  cord  Such  delay  may  be  of  maternal  origin,  from  inefficient  contrac- 
tions, pendulous  abdomen,  etc.  Fetal  causes  include  actual  shortness  of  the  um- 
bilical cord  or  relative  shortness  from  the  presence  of  loops  around  the  neck  or 
body;  failure  of  rotation;  diseases,  such  as  ascites;  deformities  of  the  fetus,  and 
relative  or  actual  largeness  of  the  fetal  shoulders  or  chest.  ( i )  If  the  pains  are 
weak,  and  after  allowing  the  uterus  a  little  rest,  stimulation  of  the  fundus  is  indi- 
cated. (2)  If  a  pendulous  abdomen  retards  expulsion,  supporting  the  abdomen 
and  uterus  and  exerting  pressure  upon  the  fundus  may  obviate  the  difficulty.  (3) 
If  expulsion  of  the  shoulders  is  retarded  by  actual  shortness  of  the  cord,  it  may 
be  necessary  to  ligateit  in  two  places  and  cut  between  the  ligatures.  If  the  cord 
is  around  the  neck,  the  loop  should  be  drawn  down  if  possible  and  passed  over  the 
head  so  as  to  relieve  it;  failing  in  this,  it  should  be  loosened  by  traction  and  the 
body  delivered  through  the  loop  (Fig.  619).  If  this  is  not  accomplished,  it  must 
be  divided  between  ligatures.  (4)  If  the  delay  is  from  failure  of  rotation,  one  may 
aid  restitution  of  the  head  and  thus  cause  rotation  of  the  shoulders  into  the  conju- 
gate diameter.  But  if  this  fails,  rotation  of  the  shoulders  maybe  obtained  by  direct 
pressure  of  the  fingers  in  the  vagina.  If  one  is  again  unsuccessful,  or  if  uterine 
stimulation  and  pressure  do  not  overcome  the  obstruction  due  to  a  large  chest, 
ascites,  or  a  monstrositv,  extraction  of  the  shoulders  is  indicated.     Mutilatory 


SHOULDER  EXTRACTION  IN   HEAD-FIRST  CASES. 


967 


operations  are  a  final  resort.      (5)   In   extracting  the  shoulders  traction  is  best 
employed  only  during  the  pains.     I  am  accustomed  to  hold  the  head  in  the  hand 


W 


V^     iCERVICb,>CRbMIALD. 


Fig.  1170. — Shoulder  Extraction  'in 
Head-first  Labors.  Directing  the  an- 
terior shoulder  well  up  behind  the  sym- 
physis, thus  securing  the  engagement  of 
the  cervico-acromial   diameter. 


Fig.  1171. — Shoulder  Extraction  in 
Head-first  Labors.  Delivery  of  the 
posterior  shoulder,  either  spontaneously 
or  artificially. 


Fig.  1 172. — Shoulder  Extraction  in 
Head-first  Labors.  Delivery  of  the 
anterior  shoulder  by  depressing  the  head 
and  making  gentle  downward  traction 
upon  it. 


Fig.  1 173. — Extraction  of  the  Poste- 
rior Shoulder  by  Traction  with  One 
Finger  in  the  Posterior  Axilla  and 
the  Palms  of  the  Hands  upon  the 
Head. 


and  gently  raise  it  so  that  the  anterior  shoulder  is  well  up  behind  the  symphysis, 
thus  securing  at  the  outlet  the  cervico-acromial  diameter  of  the  fetus  instead  of 


968  OBSTETRIC  SURGERY. 

the  bisacromial  diameter  (Fig.  1170).  The  posterior  shoulder  is  now  delivered 
over  the  perineum  by  pressure  on  the  fundus  (Fig.  1171),  traction  on  the  head 
(Fig.  1 171)  or  in  the  axilla.  The  posterior  shoulder  is  thus  delivered  first,  con- 
trary to  the  custom  of  many.  (Compare  Shoulder  Delivery,  page  486.)  (6)  The 
anterior  shoulder,  up  to  this  time  behind  the  symphysis,  is  now  delivered  by  de- 
pressing the  head,  and  making  gentle  downward  traction  upon  it  (Fig.  11 72).  Trac- 
tion with  a  finger  in  the  anterior  axilla  may  be  necessary.  (7)  Some  advise  push- 
ing up  the  anterior  shoulder  until  the  neck  is  under  the  pubic  arch,  drawing  down- 
ward until  the  posterior  shoulder  is  at  the  edge  of  the  perineum,  then  carr3dng  the 
head  backward,  so  that  the  anterior  shoulder  may  emerge  under  the  arch  (Fig. 
1 173).  (8)  Blunt  hooks  are  sometimes  advised  for  exerting  traction  in  place  of 
the  finger.  Either  may  cause  fracture  of  the  humerus,  separation  of  its  epi- 
physis, or  temporary  paralysis  of  the  arm.  The  blunt  hook  is  the  more  likely 
to  cause  such  damage. 


V.  BREECH  EXTRACTION. 

The  general  rule  for  the  conduct  of  labor  with  breech  presentation  is  to  do  only 
what  is  necessary  to  prevent  early  rupture  of  the  membranes  and  so  to  obtain  as 
complete  dilatation  of  the  parturient  canal  as  possible  before  passage  of  the  head. 
If  everything  progresses  favorably,  the  physician  is  called  upon  to  do  nothing 
until  the  umbilicus  is  delivered,  except  to  support  the  trunk  after  it  is  bom,  and 
to  watch  the  fundus  carefully  and  constantly  in  order  to  prevent  displacement  of 
the  arms  above  the  head.  Occasionally,  however,  the  breech  may  be  arrested 
either  above  or  at  the  brim,  or  in  the  pelvic  cavity. 

Dangers. — Injury  to  either  the  mother  or  the  fetus  may  result  from  breech 
extraction.  Fracture  or  dislocation  of  the  femur  of  the  fetus,  injury  of  the  femo- 
ral blood-vessels,  or  temporary  paralysis  of  the  lower  extremities  may  follow 
traction  by  any  method  involving  pressure  in  the  groin,  but  is  most  likely  to  take 
place  when  the  blunt  hook  is  used.  Laceration  of  the  maternal  soft  parts  may  be 
caused  by  a  slipping  of  the  blunt  hook  or  of  the  forceps  applied  to  the  breech. 
The  forceps  may  also  injure  the  spinal  cord  or  abdominal  organs  of  the  fetus, 
and  the  blunt  hook  the  genitals.  It  is  thus  seen  that  serious  results  may 
follow  the  application  of  the  forceps  or  the  careless  use  of  the  blunt  hook,  and 
therefore  these  procedures  should  not  be  indiscriminately  employed. 


(A)  ARREST  OF  THE  BREECH  ABOVE  THE  PELVIC  INLET. 

Obliquity  of  the  uterus  may  cause  the  breech  to  rest  upon  the  pelvic  brim,  pre- 
venting its  advance.  When  this  occurs,  the  fetus  may  be  raised  slightly  and  the 
breech  pushed  over  the  pelvic  inlet  and  held  in  that  situation  until  it  has  engaged. 
This  manceuver  may  be  executed  by  external  abdominal  manipulation  or  by  two 
fingers  in  the  vagina  or  by  the  two  combined. 


(B)  ARREST  OF  THE  BREECH  AT  THE  INLET. 

This  may  be  due  to  contraction  or  deformity  of  the  pelvis  or  to  unusual  size 
ofjj^the  fetus.  At  times  the  obstacle  may  be  overcome  by  simple  pressure  upon 
the  fundus.      If  this  fails  breech  extraction  may  be  demanded  for  the  following 


BREECH   EXTRACTION. 


969 


indications:  on  the  part  of  the  mother:   (i)  Exhaustion  from  prolonged  efforts  at 
expulsion,  (2)  severe  hemorrhage,  (3)   rise   of  temperature,  (4)  convulsions,  (5) 

prolonged  compression  of  the  soft  parts 
(6)  varicosities  or  oedema  of  the  exter- 
nal genitals.    Indications  on  the  part  of 
i  the    fetus    are:     (i)  Commencing    as- 

phyxia,  shown   by  increased   rapidity 
and  later  slowness  and  irregularity   of 
i  the  fetal  heart;  (2)  prolapse  of  the  cord. 


Fig.  1 174. — Breech  Extraction  with  the 
Breech  at  or  above  the  Pelvic  Inlet. 
Bringing  down  the  Anterior  Leg. 


Fig.  1175. — -Breech  Extraction.  Delivery 
of  a  Small  or  Premature  Fetus  by 
Direct  Manual  Traction  upon  the 
Breech,  the  Thumb  and  Third  and 
Fourth  Fingers  in  the  Groins,  and  the 
First  and  Second  Fingers  over  the 
Back  of  the  Fetus. 


Arrest  of  the  breech  at  the  brim  of  the  pelvis  may  be  overcome  by  one  of  the 
following  procedures,  which  can  be  assisted  by  pressure  upon  the  fundus.  Which- 
ever method  is  employed,  it  is 
imperative  to  keep  the  fundus 
closely  in  contact  with  the  fetus, 
in  order,  as  has  been  stated  above, 
to  prevent  displacement  of  the 
upper  extremities  above  the  head. 
Any  form  of  traction  used  should 
be  exerted  only  during  the  pains. 
I.  Traction  upon  a  Leg 
Brought  Down  (Fig.  1174). — 
Under  anesthesia  the  hand  whose 
palm  can  most  conveniently  be 
placed  upon  the  abdominal  sur- 
face of  the  fetus  is  introduced  into 
the  uterus  in  this  position.  The 
anterior  foot  is  seized  and  brought 
down.  It  is  important  that  this 
foot  should  be  chosen  rather  than 

the  posterior,  because  in  the  latter  event  traction  tends  to  bring  the  anterior 
buttock  over  the  front  portion  of  the  brim  of  the  pelvis,  thus  preventing  descent. 


"'^.. 


-^E3:£2& 


ov 


Fig.  1 176. — Double  Sling  Applied  to  the 
Breech,  showing  Faulty  and  Correct  Lines 
OF  Traction. 


970 


OBSTETRIC  SURGERY. 


Care  must  be  taken  that  prolapse  of  the  cord  does  not  occur  when  the  foot  is 
brought  down.  After  the  foot  has  been  drawn  out  of  the  vulva  traction  on  it  is 
exerted  downward  and  backward  in  the  axis  of  the  pelvic  inlet  (Fig.  1179).  Pres- 
sure upon  the  fundus  aids  in  bringing  the  posterior  groin  within  reach,  when  one 
or  two  fingers  introduced  into  it  may  further  assist  extraction  by  distributing  the 
force  over  both  lower  extremities  and  so  diminishing  the  danger  of  injury  to  the 
one  brought  down  (Fig.  1180).  The  other  foot  may  be  brought  down  also,  but 
better  dilatation  of  the  soft  parts  is  obtained  when  this  is  not  done.  Traction 
downward  and  backward  is  continued,  the  extremities  being  wrapped  in  a  hot 
sterile  towel.  As  the  breech  emerges  it  is  drawn  forward  to  avoid  lacerating  the 
perineum.  If  the  legs  are  extended  along  the  bod5^  and  this  is  discovered  early  by 
abdominal  palpation  before  rupture  of  the  membranes,  the  difficulty  can  be  over- 
come by  external  cephalic  version.  If  not  seen  until  later,  great  care  must  be  used 
in  flexing  the  extended  leg.     I  introduce  the  hand  as  far  as  the  popliteal  space, 


Fig.    1 177. — ^Breech   Extraction.     Sling    Applied  to  the  Anterior  and  the  Blunt 

Hook  to  the  Posterior  Groin. 


and  with  two  fingers  encircling  the  upper  third  of  the  leg  gently  flex  the  same 
downward.  The  leg  and  the  foot  are  thus  easily  reached  and  brought  down.  This 
procedure  is  better  than  that  of  introducing  the  hand  deep  into  the  uterus  to 
reach  the  feet  near  the  fundus. 

2.  Digital  Traction.— If  a  foot  is  not  or  cannot  be  brought  down,  a  finger 
passed  through  the  anterior  groin  may  serve  for  applying  traction.  As  soon  as 
this,  aided  by  pressure  upon  the  fundus,  has  brought  the  posterior  groin  within 
reach,  two  fingers  of  the  other  hand  in  this  groin  can  be  used  to  assist.  Various 
modifications  of  digital  traction  are  advised  by  different  operators.  Some  apply 
pressure  in  the  posterior  groin  by  an  index-finger  in  the  mother's  rectum  while 
the  corresponding  finger  of  the  other  hand  is  employed  in  the  anterior  groin. 
Others  exert  traction  by  the  whole  hand  in  the  vagina  with  the  thumb  oyer 
one  iliac  crest  of  the  fetus  and  the  little  finger  over  the  other,  while  the  remain- 
ing fingers  are  extended  along  the  back  (Fig.  1175). 


BREECH  EXTRACTION. 


971 


3.  The  Fillet  (Fig.  11 76). — This  may  be  used  when  the  groin  cannot  well  be 
reached  in  order  to  exert  traction,  and  also  when  a  greater  amount  of  force  is  re- 
quired than  can  be  commanded  by  the  digital  method.  The  fillet,  a  strip  of 
sterile  bandage,  is  passed  up  to  and  across  the  anterior  groin  and  down  on  the 
other  side  of  the  thigh,  forming  a  loop  over  the  groin.  Some  obstetricians  employ 
a  second  fillet  over  the  opposite  inguinal  region  in  order  to  be  able  to  use  greater 
force  without  increasing  the  strain  upon  one  portion  of  the  bod3^  The  fillet  may 
be  carried  into  position  by  a  loop  of  string  attached  to  a  catheter  containing  a 
stylet  (Fig.  11 09).  The  latter  is  bent  so  as  to  form  a  curve,  which  when  passed  up 
to  the  groin,  turned  toward  the 

child's  abdomen,  and  drawn 
down  into  the  groin,  will  bring 
its  tip,  threaded  with  a  loop  of 
string,  between  the  thighs  of  the 
fetus.  This  loop  is  seized,  drawn 
down,  and  fastened  to  the  fillet. 
When  the  catheter  and  stylet  are 
withdrawn  the  fillet  passes  into 
position.  In  exerting  traction 
by  means  of  the  fillet,  care  must 
be  taken  to  pull  during  the  pains 
in  such  a  direction  as  to  corre- 
spond with  the  mechanism  of 
labor  and  so  to  diminish  the 
liability  to  fracture  the  femur. 

4.  The  Blunt  Hook  (Fig. 
1 1 7  7 ) . — A  blunt  hook,  consisting 
of  a  straight  shank  with  an  ex- 
tremity whose  curve  should  be 
such  as  to  fit  the  inguinal  region 
of  the  fetus,  is  advised  by  some 
as  affording  means  for  stronger 
traction.  It  is  passed  up,  as  is 
the  catheter  for  placing  the  fillet, 
between  two  fingers  of  the  left 
hand  and  the  child's  body.  Its 
point  is  rotated  so  that  when 
drawn  down  its  curve  lies  in  the 
groin  and  its  point  is  felt  be- 
tween the  thighs.  The  same 
precautions  must  be  taken  in 
regard  to  the  line  of  traction  as 

with  the  fillet.     With   this,  as  with   the  fillet,  a   finger  in  the  groin  may  assist 
when  the  breech  has  been  brought  sufficiently  low. 

5.  Forceps. — This  may  be  applied  to  the  breech  as  a  last  resort 
ceps,  page  1003.) 


Fig.  117S.; — Breech  Presentation  with  the  Left 
OR  Anterior  Buttock  Caught  at  the  Pelvic 
Inlet  behind  the  Symphysis,  as  the  Result 
OF  Faulty  Traction  on  the  Prolapsed  Leg  in 
A  Horizontal  Plane. 


(See  For- 


ce) ARREST  OF  THE  BREECH  IN  THE  PELVIC  CAVITY. 

When  impaction  of  the  breech  occurs  in  the  pelvic  cavit}^  it  is  usually  impos- 
sible to  bring  down  a  foot.  The  obstetrician  must  rely  upon  external  abdominal 
pressure  alone,  or  combined  with  digital  traction  in  the  groin,  or  the  use  of  the 


972 


OBSTETRIC  SURGERY. 


\     f- 


,y 


Fig.   1 179. — Breech  Extraction.     Trac- 
tion ON  A  Leg. 


Fig.  1 180. — Breech  Extraction.  Trac- 
tion ON  THE  Anterior  Leg  and  Groin 
AND  Posterior  Groin. 


;! 


Fig.  1 181. — Breech  Extraction.     Trac- 
tion ON  Both  Groins. 


/ 


Fig.  1 182. — Breech  Extraction.     Down- 
ward Traction  on  the  Groins. 


\-^ 


V  V  I 


L^>lMMMHi<MM> 


Fig.   1 183. — Extraction    of   the    After-coming   Head.     Delivery   of  the   Posterior 

Arm. 


BREECH   EXTRACTION .  973 

fillet  or  blunt  hook.  The  forceps  may  be  employed  as  in  cases  of  arrest  at  the 
brim.  Symphyseotomy  has  been  advised  in  these  cases.  When  the  child  is 
dead  and  other  methods  have  failed,  the  cranioclast  applied  to  the  breech  will 
usually  succeed  in  effecting  delivery.  One  blade  is  introduced  into  the  fetal 
rectum,  the  other  applied  over  the  sacrum  (Fig.  1147),  or  the  cephalotribe  may 
be  applied  over  the  trochanters  and  sides  of  the  pelvis  if  it  is  necessary  to  diminish 
the  breadth  of  the  breech  (Fig.  1154). 

The  uterus  must  be  made  to  retract  closely  over  the  fetus  during  the  whole 
period  of  its  delivery.  This  is  best  accomplished  by  having  an  assistant  grasp 
the  fundus  with  both  hands,  making  a  funnel,  thus  preserving  head  flexion  and 
reducing  the  danger  of  displacement  of  the  arms  (Fig.  1167).  Traction  should 
be  made  during  the  pains  when  the  latter  are  not  too  far  apart;  it  should  be 
slow  to  allow  the  uterus  completely  to  retract  and  thus  lessen  the  danger  of 
hemorrhage;  the  direction  of  the  traction  should  be  downward  and  somewhat 
backward,  and  steady  tractions  are  preferable  to  rotary  or  pendulum  movements. 

Extraction  by  the  Feet  (Fig.  11 79). — If  a  single  leg  presents,  the  foot  is 
seized  between  the  middle  and  index  fingers  with  the  thumb  on  the  sole,  and  when 
the  leg  is  drawn  outside  the  vagina  it  is  wrapped  in  a  warm  towel  and  grasped 
with  the  whole  hand,  the  thumb  always  being  directed  upward  and  applied  to 
the  dorsal  surface  of  the  leg.  The  fetus  as  delivered  should  always  be  covered 
with  warm  moist  towels  (100°  F.  )  to  lessen  the  danger  of  the  air  of  the  delivery 
room  (70°  to  80°  F.)  exciting  respiratory  movements.  The  direction  of  the 
traction  should  be  sufficiently  backward  to  avoid  friction  at  the  pubic  arch,  and 
until  the  buttocks  appear  the  extracting  hand  should  shift  upward  so  as  to  grasp 
the  leg  as  near  the  maternal  parts  as  possible;  whichever  leg  is  seized  rotates  for- 
ward into  the  pubic  angle  during  extraction.  Should  both  legs  present  in  the 
vagina,  the  middle  finger  is  placed  between  the  feet  and  the  index  and  ring  fingers 
encircle  the  external  malleoli  until  the  legs  are  delivered,  when  the  right  leg 
should  be  seized  with  the  right  hand  and  the  left  with  the  left  hand.  The  nor- 
mal rotation  of  the  fetus  can  thus  be  controlled.  Leg  traction  should,  by  reason 
of  the  dangers  of  dislocation  and  fracture,  be  discontinued  as  soon  as  the  buttocks 
have  been  brought  into  the  vulval  outlet,  when  traction  on  the  breech  should  be 
substituted  (Figs.  1180,  1181,  1182). 

Extraction  by  the  Breech  (Fig.  1183). — The  fetal  pelvis  is  grasped  by  inserting 
an  index-finger  in  each  groin,  placing  the  thumbs  over  the  fetal  sacrum,  and 
steadying  the  remaining  three  fingers  of  each  hand  over  the  corresponding 
thighs.  Following  the  normal  mechanism,  the  fetus  is  now  slowly  extracted 
until  the  lower  angle  of  the  anterior  scapula  appears,  during  which  time  atten- 
tion should  be  paid  to  the  cord. 

Management  of  the  Cord. — Should  the  cord  be  found  between  the  child's  legs, 
the  placental  extremity  should  be  drawn  down  and  the  loop,  if  possible,  slipped 
over  the  posterior  thigh.  In  rare  cases,  when  this  procedure  fails,  the  cord  should 
be  cut  between  two  ligatures.  In  all  cases  as  soon  as  the  umbilicus  appears  at  the 
vulva  the  cord  should  gently  be  drawn  down  a  few  inches  and  placed,  if  possible, 
in  the  posterior  segment  of  the  outlet,  in  order  to  avoid  dangerous  traction  upon 
the  navel. 


974 


OBSTETRIC  SURGERY. 


(/) 


v.. 


Fig 


VI.    EXTRACTION  OF  THE  AFTER-COMING  HEAD. 

Delivery  of  Displaced  Arm.  (2)  Manual  Rotation  of  Transversely  Placed  Head,  (j) 
Uterine  Compression.  (4)  F ace-and-shoulder  Traction,  or  Sm-ellie  Method.  (5)  Jaw- 
and-shoulder  Traction,  or  Method  of  Smellie-Veit,  Mauriceau.  (6)  Jaw  Traction  and 
Suprapubic  Pressure,  or  Wigand-A.  Martin  Method.  (7)  Jaw,  Shoulder  Traction,  and 
Suprapubic  Pressure,  or  the  Combined  Method.  (<?)  Foot-and-shoulder  Traction,  or 
Prague  Method,  (p)  Forceps  for  the  After-coming  Head.  {10)  Delivery  of  the  Head  in 
Persistent  Sacro-posterior  Cases. 

It  should  be  remembered  that  in  all  breech  cases  delivery  must  be  completed 
within  five  to  ten  minutes  of  the  emergence  of  the  umbilicus,  as  the  pressure  ex- 
erted upon  the  cord  will  usually  result  in  fatal  asphyxia  if  continued  longer  than 

that  time.  It  is  also  to  be 
understood  that  during  all 
these  manipulations  the 
body  of  the  child  is  to  be 
wrapped  in  hot,  sterile 
towels,  as  diminution  of 
the  body-temperature  is 
extremely  dangerous.  In 
the  following  descriptions 
the  direction  of  traction  is 
described  in  relation  to  the 
long  axis  of  the  mother's 
body;  thus,  downward 
means  toward  her  feet; 
backward  signifies  toward 
the  floor  if  she  lies  upon 
her  back. 

Dangers.  —  Traction 
upon  the  legs '  may  cause 
separation  of  the  epiphy- 
ses. Pressure  upon  the 
clavicles  by  the  hand 
grasping  the  shoulders  may 
fracture  them  and  cause 
paralysis  of  the  upper  ex- 
tremities by  pressure  upon 
the  brachial  plexus.  Dis- 
location of  the  cervical  ver- 
tebrae with  laceration  of 
the  spinal  cord  is  more 
likely  to  result  from  the 
use  of  the  Prague  method 
than  from  any  other.  Such 
traction  may  also  cause 
laceration  of  blood-vessels 
and  may  result  in  hema- 
toma of  the  sternocleido- 
mastoid. The  compression  to  which  the  cord  is  subjected,  particularly  in  forceps 
delivery  or  birth  of  the  head  of  a  persistent  sacro-posterior  case,  may  cause  cere- 
bral hemorrhage  or  fracture  of  the  skull.  Traction  on  the  jaw  by  the  finger  in  the 
mouth  may  lead  to  dislocation.     Misdirected  force  in  bringing  down  an  extended 


1 184. — Extraction  OF  the  After-coming  Head. 
Delivery  of   the  Posterior  Arm. 


^ 


^ 


Fig.  1 185. — Extraction  of  the  After-coming  Head. 
Delivery  of  the  Posterior  Arm. 


EXTRACTION   OF  THE  AFTER-COMING  HEAD. 


975 


\ 


s> 


arm  may  cause  fracture  of  the  humerus,  and  attempts  to  cause  rotation  of  the 
head  by  force  exerted  upon  the  trunk  alone  may  dislocate  the  cervical  vertebras. 

1.  Delivery  of  the  Extended  Arms  (Figs.  1183  to  1189). — One  arm  or  both  may 
become  extended  from  too  energetic  traction  upon  the  body  of  the  fetus  in  simple 
breech  presentations,  or  this  may  occur  during  the  necessary  manipulations  in  the 
delivery  of  an  impacted  breech;  and,  indeed,  without  these  causes  the  arms  may 
become  extended  at  full  length,  beside  the  child's  head.  Before  delivery  of  the 
head  is  possible,  unless  the  child  is  very  premature,  the  arms  must  be  brought 
into  a  normal  position.  The  posterior  arm  should  first  be  manipulated,  as  the 
sacral  hollow  gives  more  room  than  there  is  anteriorly.  The  child's  legs  being 
grasped  by  the  operator's  left  hand  just  above  the  malleoli,  its  body  is  carried 
upward  and  flexed  over  the  mother's  right  hip  in  left  sacro-positions,  and  over 
the  left  hip  in  right  sacro-positions  (Fig.  1184).  This  moves  the  jDOsterior  fetal 
shoulder  down  into  the  pel- 
vis. The  operator's  index 
and  middle  fingers  of  the 
hand  whose  palm  corre- 
sponds to  the  dorsum  of  the 
fetus  are  inserted  into  the 
vagina  till  the  child's  sca- 
pula is  reached,  and  then 
along  the  back  of  the  arm  to 
the  elbow,  which  is  pulled 
forward  into  the  sacral  cav- 
ity so  that  the  child's  arm 
comes  in  front  of  its  face. 
By  hooking  a  finger  through 
the  elbow-joint  and  pulling 
downward  the  arm  is  flexed, 
and  by  extension  the  fore- 
arm is  delivered  on  the  chest 
of  the  fetus  (Fig.  1 186).  The 
process  is  now  reversed  and 
the  right  hand  grasps  the 
fetal  body  and  carries  it  over 
the  mother's  left  thigh,  etc., 
till  the  other  arm  is  deliv- 
ered. These  manipulations  must  be  conducted  with  great  gentleness  and  care 
to  avoid  fracture  of  the  humerus. 

Dorsal  Displacement  of  the  Arm  (Fig.  694). — A  far  less  common  accident 
than  simple  extension  is  dorsal  displacement  of  the  arm.  The  arm  is  extended 
along  the  head,  the  elbow  flexed,  and  the  forearm  behind  the  neck.  This  displace- 
ment may  result  from  attempts  to  rotate  the  trunk  or  head,  the  arms  not  rotating 
with  the  bod}^  and  so  passing  behind  it.  This  constitutes  a  serious  obstacle  to 
delivery,  as  the  forearm  prevents  the  occiput  from  passing  under  the  pubic  arch. 
It  is  overcome  by  rotating  the  body  in  the  direction  opposite  to  that  which 
caused  the  displacement,  thus  bringing  the  arm  in  front  of  the  fetal  head. 
The  extremity  may  then  be  drawn  down,  as  in  the  case  of  simple  extension 
of  the  arm  above  the  head.  If  the  occiput  has  been  directed  posteriorly  by 
the  manoeuvers  and  fails  to  rotate  forward  at  once  after  extraction  of  the  arm, 
this   should  be  brought   about  artificially  in  the  following  manner. 

2.  Manual  Rotation  of  the  Transversely  Placed  Head  (Figs.   11 90,    1191). — 


MttlMHtMMMaMbAIM 


Fig.  1 186. — Extraction  of  the  After-coming  Head. 
Delivery  of  the  Posterior  Arm. 


976 


OBSTETRIC  SURGERY. 


When  the  head  presses  with  its  long  diameter  transverse  or  with  the  occiput  in 
the  sacral  hollow,  the  head  and  trunk  should  be  firmly  held  by  the  SmelHe  or 
Smellie-Veit  grasp,  and  rotated  so  as  to  bring  the  occiput  to  the  front,  when 
the  dehvery  can  be  completed.  (See  below.)  Rotation  by  grasping  the  trunk 
alone  must  be  carefully  avoided,  as  it  is  Hable  to  cause  injury  to  the  spinal  cord 


„=^^5*^?>^^5S^v*.,5^--^ 


V. 


Fig.  1 187. — Extraction  of  the  Aftercom- 
iNG  Head.  Rotation  of  the  Fetus  in 
Order  to  Bring  the  Anterior  Arm  in 
the  Posterior  or  Roomier  Segment  of 
THE  Pelvis. 


Fig.  1 188. — -Extraction  of  the  After- 
coming  Head.  Delivery  of  the 
Arms  in  the  Sacro-posterior  Posi- 
tion OP  THE  Fetus. 


■y- 


f 


X 


Fig.  1 189. — Extraction  of  the  After-coming  Head.     Delivery  of  the  Arms  in  the 
Sacro-posterior  Position  of  the  Fetus. 


if  the  head  fails  to  rotate  at  the  same  time.  I  have  found  that  one  finger  in 
the  child's  mouth,  the  thumb,  third,  and  fourth  fingers  over  the  shoulders,  and 
the  second  and  third  fingers  on  the  occiput  is  a  very  reHable  method  for  head 
rotation  (Figs.  1191,  1193). 

3.  Uterine  Compression  (Fig.   1194). — When  conditions  arise  that  demand 
speedy  dehvery,  it  may  be  attained  by  suprapubic  uterine  compression.     Uterine 


EXTRACTION   OF  THE   AFTER-COMING  HEAD. 


977 


compression  is  of  great  value  and  power  in  expelling  the  head,  as  the  force  is  ex- 
erted almost  directly  upon  the  head  itself.  Applied  by  a  trained  assistant  it 
may  advantageously  be  combined  with  the  Smellie  or  Smellie-Veit  method. 

4.  Face-and-shoulder  Traction,  or  Smellie  Method. — The  operator's  right  or 
left  hand  is  passed  between  the  thighs  and  then  between  the  arms  of  the  child, 
whose  body  rests  upon  the  forearm  while  the  arms  and  legs  hang  down  at  each 
side.     For  face  traction  that  hand  should  be  chosen  the  palm  of  whicn  naturally 


Fig.  1 190. — Extraction  of  the  After- 
coming  Head.  Manual  Rotation  of 
the  Fetus  in  Order  to  Favor  Ante- 
rior Rotation  of  the  Occiput  in 
Sacro-posterior  Positions. 


Fig.  1 191. — -Extraction  of  the  After- 
coming  Head.  Manual  Rotation  of 
the  Transversely  Placed  Head.  The 
upper  figure  shows  the  rotation  com- 
pleted. 


corresponds  with  the  face  of  the  fetus;  thus,  the  right  hand  when  the  face  looks 
to  the  left,  and  vice  versa.  The  index  and  middle  fingers  of  this  hand  enter  the 
vagina  and  their  tips  are  placed  one  at  each  side  of  the  child's  nose.  The  other 
hand  grasps  the  shoulders  from  behind,  the  index-finger  over  one,  the  other  three 
fingers  over  the  other  clavicle.  The  tips  of  these  fingers  first  aid  flexion  of  th  e  head 
by  pressing  the  occiput  upward,  while  the  fingers  appHed  to  the  face  of  the  fetus 
attempt  to  draw  it  down.  When  the  head  is  well  flexed,  traction  is  made  down- 
62 


978  OBSTETRIC  SURGERY. 

ward  with  both  hands,  the  second  grasping  the  shoulders  as  described.  As  soon  as 
the  occiput  is  well  engaged  under  the  pubic  arch  the  body  is  raised  over  the 
mother's  abdomen  while  the  fingers  of  the  internal  hand  continue  to  exert  trac- 
tion, as  those  of  the  external  do  upon  the  shoulders.  As  the  face  emerges  over  the 
perineum  the  shoulder  hand  must  leave  the  shoulders  and  protect  the  perineum  by 
drawing  the  vulval  tissues  backward  and  toward  the  median  line  and  by  prevent- 
ing sudden  expulsion  of  the  forehead.  This  method  of  traction  is  inferior  to  the 
following,  also  recommended  by  Smellie,  because  the  fingers  on  the  face  of  the  child 
cannot  secure  a  firm  grasp  upon  the  slippery  skin  for  traction.  It  was  suggested 
by  him  as  avoiding  danger  to  the  jaw,  which  the  Smellie-Veit  method  involves. 
5.  Jaw-and-shoulder  Traction,  or  Method  of  Smellie-Veit  or  Mauriceau 
Method  (Fig.  11 96). — This  manoeuver  differs  from  the  last  only  in  that  traction  is 
applied  by  the  index-finger  in  the  mouth  instead  of  by  two  fingers  upon  the  face. 
It  affords  a  far  more  effectual  grasp  upon  the  face.  Great  care  is  necessary  lest 
the  lower  jaw  be  injured  by  the  use  of  excessive  force. 


^/ 


Fig.  1 192. — Extraction  of  the  After-  Fig.  1193. — -Extraction  of  the  After- 
coming  Head.  Digital  Flexion  of  an  coming  Head.  Digital  Flexion  of  a 
Extended  Head  Above  the  Pelvic  Partially  Extended  Head  at  the  Pel- 
Inlet,  vic  Inlet. 

6.  Jaw  Traction  and  Suprapubic  Pressure,  or  Wigand-A.  Martin  Method  (Fig. 
1 1 97). — The  child's  body  lies  astride  the  operator's  right  or  left  arm,  as  in  the  pre- 
ceding methods,  while  the  fingers  are  inserted  into  the  vagina,  the  index-finger 
being  passed  into  the  infant's  mouth  so  that  by  traction  complete  flexion  of  the 
head  may  be  secured.  The  fingers  of  the  remaining  hand  are  placed  on  the  ab- 
domen over  the  occiput  which  lies  just  above  the  symphysis.  By  the  combina- 
tion of  the  pressure  above  in  the  axis  of  the  parturient  canal  and  the  traction  be- 
low, the  head  is  delivered.  On  the  appearance  of  the  head  at  the  vulva  the 
child's  body  is  carried  upward  toward  the  mother's  abdomen,  which  lessens 
the  danger  of  perineal  laceration. 

7.  Jaw,  Shoulder  Traction,  and  Suprapubic  Pressure,  or  Combined  Method 
(Fig.  II 98). — In  difficult  cases  it  is  advisable  to  use  a  combination  of  the  above 
methods,  namely,  the  operator  performs  jaw-and-shoulder  traction  as  in  the 
Smellie-Veit  method,  while  suprapubic  pressure,  as  in  the  expression  of  the  fetus, 
is  made  by  a  competent  assistant. 


EXTRACTION   OF  THE   AFTER-COMING  HEAD. 


979 


8.  Foot-and-shoulder  Traction,  or  Prague  Method  (Fig.  1199). — One  of 
the  operator's  hands  grasps  the  child's  feet  from  behind,  the  middle  finger 
passing  between  the  ankles.  The  other  hand  grasps  the  child's  shoulders 
as  in  the  Smellie  method,  and  downward  and  backward  traction  is  exerted 
by  both  hands  till  the  perineum  is  well  distended  by  the  head.  The  hand 
grasping  the  shoulders  is  now  used  as  a  fulcrum  around  which  the  head 
is  rotated  by  raising  the  body  and  lower  extremities  over  the  mother's  abdomen 
while  continuing  to  exert  traction  with  the  hand  holding  the  ankles.  This 
method  involves  the  use  of  great  force,  which  may  cause  dislocation  or  fracture 
of  the  neck  or  clavicles  of  the  child,  and  should  never  he  employed. 


Fig.  1 194. — Extraction  of  the  After-coming  Head.     Suprapubic  Uterine  Compres- 
sion.— {From  a  photograph  taken  at  the  Emergency  Hospital.) 


9.  Forceps  for  the  After-coming  Head.  (See  Forceps, page  1003). — This  method 
is  rapid  and  valuable  and  may  be  used  when  the  other  methods  fail.  The  child's 
body  is  carried  up  over  the  maternal  abdomen.  The  blades  of  the  forceps  are 
applied  to  the  fetal  head  and  delivery  proceeds  as  in  the  usual  forceps  operations. 
It  is  used  only  after  failure  of  manual  extraction  and  never  in  cases  with  the 
head  above  the  inlet. 

10.  Delivery  of  Head  in  Persistent  Sacro-posterior  Cases  (Figs.  1200). — If 
manual  rotation,  as  described  above,  of  the  head  whose  occiput  fails  to  rotate 
anteriorly  is  unsuccessful,  the  head  must  be  extracted  with  the  face  anterior. 
This  is  accomplished  in  one  of  two  ways:  (i)  If  the  chin  is  caught  above  the  sym- 
physis, traction  upon  the  fetus  should  be  directly  forward  toward  the  ceiling  when 


980 


OBSTETRIC  SURGERY. 


the  woman  is  in  the  dorsal  position.  External  abdominal  pressure  is  made  down  - 
ward  and  backward  upon  the  head  at  the  same  time.  The  head  rotates  around  the 
symphysis  and  the  occiput  is  bom  first.  (2)  If  the  chin  is  below  the  symphysis, 
the  woman  is  placed  upon  her  back  with  the  hips  over  the  edge  of  the  bed  or 
table,  so  that  traction  can  be  exerted  directly  backward — toward  the  floor.     The 


Fig.  1 195. — Extraction  ok  the  After-coming  Head. 

Smellie  Method. 


Face  and  Shoulder  Traction, 


Other  hand  presses  downward  upon  the  head  above  the  pubis,  and,  if  necessary,  a 

finger  in  the  rectum  can  further  increase  flexion  of  the  head  by  pushing  up  the 

occiput.     Jaw  traction  will  also  assist.     By  this  method  the  face  is  bom  first. 

Method  Advised. — As  a  general  rule,  preference  should  be  given  to  the  Smellie- 


FlG      II96. 


-Extraction  of  the   After-coming    Head.     Jaw-and-shoulder  Traction. 
Mauriceau  or  Smellie-Veit  Method. 


Veit  method,  combined  with  suprapubic  uterine  compression  by  a  trained  assist- 
ant, or  the  Wigand-Martin  method  if  unassisted  and  the  Smellie-Veit  fails.  If 
these  are  not  successful,  the  forceps  must  be  rapidly  applied,  remembering  that 
five  to  ten  minutes  is  the  allotted  time  from  the  appearance  of  the  umbilicus 
to  the  birth  of  the  head. 


EXTRACTION   OF  THE   AFTER-COMING  HEAD. 


981 


I 


X 


»>lirt»itffii;>^iit"iiwiifiwiituii  

''^'""■"  ""• 

D 

Fig.    11Q7. — Extraction  of  the  After-coming  Head.     Jaw  Traction   Combined  with 
Suprapubic  Pressure.     Wigand-A.  Martin  Method. 


Fig.   119S. — ^Extraction  of  the  After-coming  Head.     Jaw,  Shoulder  Traction,  and 
Suprapubic  Pressure.     The  Combined  Method. 


982 


OBSTETRIC  SURGERY 


Fig.    1 199. — Extraction  of  the  After-coming  Head.     Sacro-posterior  Position. 
Shoulder  and  Leg  Traction.     Prague  Method. 


>y 


J 


Fig.    1200. — Extraction   of   the   After-coming    Head.     Persistent   Sacro-posterior 
Position.     Jaw  and  Shoulder  Traction  and  Extension  of  the  Fetus. 


THE   FORCEPS.  983 


VII.  THE  FORCEPS. 

Historical. — This  instrument  in  some  form  evidently  dates  back  to  some  time  before 
the  Christian  era,  as  crude  patterns  of  it  have  been  found  in  connection  with  archaeological 
investigations  in  Egypt  and  elsewhere.  By  reason  of  the  complete  silence  of  classical 
authors  upon  so  important  a  subject  as  instrumental  extraction  of  living  children,  it  has 
been  assumed  that  the  forceps  of  that  period  was  used  only  for  the  extraction  of  dead 
fetuses.  Somewhere  about  1600  it  is  believed  that  Peter  Chamberlen,  of  London,  began 
to  use  the  forceps  as  a  matter  of  routine  in  obstetrical  practice.  We  do  not  really  know 
when  or  by  whom  it  was  invented,  nor  how  the  inventor  was  influenced  toward  his  inno- 
vation. It  is  certain,  however,  that  the  Chamberlens  possessed  a  monopoly  of  the  instru- 
ment, and  that  the  secret  was  virtually  preserved  among  the  members  and  pupils  of  the 
family  until  the  independent  invention  of  a  forceps  by  Palfyn  in  1723,  together  with  Chap- 
man's published  description  of  Chamberlen's  instrument  in  1725,  had  made  this  discovery 
the  common  property  of  the  profession.  The  Chamberlen  forceps  consisted  of  fenestrated 
blades  joined  to  a  scissor-like  handle.  The  cephalic  curve  was  admirable,  but  there  was 
no  pelvic  curve,  shank,  or  lock.  After  adaptation  the  blades  were  held  in  place  by 
tape  wound  tightly  between  the  handles  and  blades  where  the  halves  cross.  The  absence 
of  pelvic  curve  and  shank  shows  conclusively  that  the  Chamberlens  practised  nothing  but 
the  low  operation.  After  knowledge  of  the  forceps  had  become  the  common  property 
of  the  profession,  but  a  few  years  elapsed  before  the  good  results  of  publicity  became  appar- 
ent. Levret,  the  leading  obstetrician  of  his  age  and  a  man  of  mechanical  genius,  added  at 
one  stroke  the  pelvic  curve,  shank,  and  lock  (about  1747).  The  modern  long  forceps  has 
undergone  but  little  alteration  since  his  time.  Smellie,  his  great  British  contemporary, 
devised  the  so-called  English  lock,  but  his  chief  service  to  midwifery  lies  rather  in  his  dis- 
coveries concerning  the  mechanism  of  labor  than  in  forceps  construction.  A  century 
elapsed  before  the  forceps  underwent  another  revolutionary  advance.  The  imperfection 
of  forceps  traction  with  the  head  at  the  brim  appears  to  have  been  recognized  during  the 
first  quarter  of  the  nineteenth  century,  and  attempts  in  the  direction  of  axis  traction  were 
made  by  attaching  traction  cords,  accessory  rods,  etc.,  to  the  blades  of  the  high  forceps. 
None  of  these  devices  was  successful  in  making  true  axis  traction,  as  the  "  line  of  pull  "  neces- 
sarily ran  within  the  birth  canal.  The  difficulty  was  overcome  to  a  certain  extent  by  using 
the  high  forceps  as  a  lever  with  the  hand  as  a  fulcrum.  Finally,  in  1877,  Tarnier  intro- 
duced to  the  notice  of  the  profession  his  axis-traction  forceps  which,  in  the  opinion  of  most 
obstetricians,  has  permanently  solved  the  problem  of  traction  at  the  inlet.  During  the 
quarter  century  just  elapsed  there  have  been  no  advances  in  forceps  construction. 

Description. — The  forceps  consists  of  two  halves  almost  identical  in  con- 
struction. They  cross  like  the  branches  of  scissors  and  interlock,  and  are  known 
as  the  arms.  The  left  arm  is  the  one  which  is  held  with  the  left  hand  and 
introduced  into  the  left  side  of  the  pelvis  and  which  contains  the  pin  or 
screw  of  the  lock.  The  right  arm,  which  is  introduced  into  the  right  side 
of  the  pelvis  with  the  right  hand,  contains  a  notch  for  the  reception  of  the 
pin  or  screw.  Each  arm  of  the  forceps  consists  of  a  blade,  shank,  handle,  and 
a  portion  of  the  lock.  The  blade  is  fenestrated  to  secure  lightness,  and  its 
free  extremity  is  termed  the  apex  (Fig.  1201).  Solid-bladed  forceps  are  pre- 
ferred by  a  few  operators,  but  by  most  are  used  only  for  special  actions,  such 
as  rotation  (Fig.  1206).  Some  authorities  reject  the  solid  blades  as  liable  to 
slip  over  the  head.  The  blade  has  a  double  curve,  one  being  on  the  fiat, 
which  corresponds  to  the  convexity  of  the  fetal  skull,  the  other  on  the  edge, 
to  conform  to  the  curve  of  the  pelvic  excavation.  These  are  known  respec- 
tively as  cephalic  and  pelvic  curves  (Fig.  1202).  When  the  instrument  is 
locked,  the  handles  come  together  to  form  a  single  grip  for  the  operator's  hand, 
and  several  devices  are  added  to  increase  the  strength  of  the  hold,  such  as  expan- 
sion at  both  ends,  and  corrugation  in  the  continuity  (Fig.  1202).  The  entire 
instrument  should  be  constructed  of  well-tempered  steel,  which  is  also  suitable 
for  ready  sterilization.  In  regard  to  correct  proportions,  the  blades  in  position 
should  be  at  least  3  inches  (7.62  cm.)  apart  at  the  acme  of  the  cephalic  curve,  and 
I  inch  (2.54  cm.)  apart  at  the  tips.  When  the  instrument  lies  upon  its  convex 
edge,  the  tips  of  the  forceps  should  be  3^-  inches  (8.89  cm.)  above  the  general 
level ;  in  other  words,  the  highest  portion  of  the  pelvic  curve  is  at  the  tip.     Forceps 


984 


OBSTETRIC  SURGERY. 


having  a  short  shank  and  no  pelvic  curve  may  be  used  for  the  low  operation,  but 
such  a  pattern  is  unnecessary,  as  the  ordinary  instrument  with  its  double  curve  and 

longer  shank  can  be  used  with  equal 
readiness  in  any  part  of  the  pelvis.  Of 
the  innumerable  patterns  of  forceps,  the 
following  are  the  most  popular:  Nae- 
gele  and  Breus  in  Germany ;  Tarnier  in 
France  (Fig.  122 1);  Simpson's  in  Eng- 
land; Simpson,  Elliott  (Fig.  1203),  and 
Tarnier  in  America. 

Antero- posterior  Forceps. — A 
French  writer,  Penoyee,*  has  devised 
a  special  form  of  forceps  in  which  one 
blade  has  a  much  greater  degree  of  cur- 
vature than  the  other,  so  that  when 
applied  at  right  angles  to  the  plane  in 
which  the  ordinary  forceps  is  used  the 
blade  with  the  more  marked  curvature 
fits  into  the  hollow  of  the  sacrum,  and 
is  thus  supposed  to  render  delivery 
easier.  It  may,  however,  be  pointed 
out  that  the  difficulties  which  require 
forceps  delivery  are  encountered  not 
while  the  head  is  in  the  hollow  of  the 
sacrum,  but  at  the  superior  strait  and 
at  the  outlet,  at  both  of  which  points 
the  peculiar  shape  of  this  forceps  is  of 
no  advantage. 

Straight  Forceps. — Forceps  without 
the  pelvic  curve  have  been  made  and 
recommended  especially  as  rotators  in 
occipito-  and  mento-posterior  positions 
of  the  head.  I  have  been  unable  to 
satisfy  myself  that  as  rotators  they  pos- 
sess any  advantages  over  the  ordinary 
instrument. 
Choice  of  Forceps. — Any  instrument  modeled  after  the  Naegele  or  Simpson 
forceps  will  prove  satisfactory.  Per- 
sonally I  prefer  the  Elliott  modifica- 
tion of  Simpson's  forceps  in  cases 
not  requiring  much  axis-traction, 
and  the  Tarnier  instrument  for  all 
high  and  difficult  cases. 

Solid-bladed  instruments  are 
convenient  for  operations  calling  for 
much  rotation,  but  the  ordinary  fen- 
estrated forceps  will  give  equally 
good  results  if  intelligently  used. 
Physicians  providing  themselves 
with  one  forceps  only,  will  do  well  to 
procure  the  latest  model  of  Tarnier's  instrument,  and  accustom  themselves  to 

*"  Revue  Clinique  d'Andrologie  et  de  Gyn6cologie,"  May  13  and  June  13,  1S95. 


Fig.  1201. — -The  Forceps.-  The  Left  Arm 
IS  the  One  which  is  Held  in  the  Left 
Hand  and  Introduced  into    the   Left 


Side  of  the  Pelvis, 
which  is  Introduced 
Side   of   the    Pelvis, 
Right  Hand. 


The  Right  Arm, 
into  the  Right 
is   Held    in    the 


Fig. 


1202.  —  The     Cephalic     and 
Curves  of  the  Forceps. 


Pelvic 


THE  FORCEPS. 


985 


its  use  in  low  as  well  as  high  cases.     One  should  see  to  it  that  the  forceps  is 
entirely  of  metal  so  as  to  withstand  frequent  boiling. 

Frequency  of  Forceps  Operations. — The  proportion  of  cases  in  which  delivery 
is  completed  with  the  forceps  naturally  varies  in  different  clinics.  During  three 
years  in  the  Paris  Maternity  (ending  March  i,  1899)  the  forceps  was  applied 
236  times  in  4380  deliveries,  about  6  per  cent.,  or  i  in  16.67.  Of  the  236  extrac- 
tions, 211  were  examples  of  the  ordinary  low  or  median  operation,  while  the 
remaining  25  were  high- forceps  cases,  all  for  contracted  pelves.*  During  one 
year  at  the  Glasgow  Maternity  there  were  187  forceps  deliveries  in  2179  confine- 
ments, about  8.5  per  cent.,  or  i  in  11. 7.  Of  482  cases  confined  at  the  Maternity 
proper,  there  was  18  per  cent,  of  forceps  intervention,  or  i  in  5.5;  while  of  1697 
women  confined  at  their  homes  by  the  Maternity  staff,  6  per  cent,  were  delivered 
by  forceps,  or  i  in  16.7.!  During  the  year  1898  there  were  6  forceps  deliveries 
in  458  confinements  at  the  Brussels  Maternity,  only  about  1.3  per  cent.,  or  i  in 
77.+  Ahlfeld  (1897)  reports  4000  cases  with  no  forceps  operations,  or  2.75  per 
cent.,  or  once  in  36.3  cases. §     In  2200  confinements  in  two  hospitals  I  found  that 


Fig.    1203. — Elliott's  Modification  of  Simpson's  Forceps. 


Fig.  1204. — McLane-Tucker  Solid-bladed  Forceps. 


the  forceps  was  applied  in  208  cases,  or  in  9.45  per  cent,  of  all  cases,  or  once  in  10.5 
cases.  In  the  208  forceps  operations,  I  found  24  were  high  operations,  43 
median,  123  low,  and  18  had  no  record  of  the  position  of  the  head  in  the  pelvis. 
Indications. — The  question,  "When  is  the  forceps  indicated?"  is  answered 
broadly  as  follows:  It  is  to  be  used  whenever  labor  is  to  be  quickly  terminated, 
whenever  the  life  of  the  mother  or  child  is  in  peril,  provided  that  contraindica- 
tions are  absent.  The  dangers  to  which  the  mother,  child,  or  both  are  exposed 
must  naturally  be  of  the  sort  which  are  removed  or  diminished  by  the  termi- 
nation of  labor.  When  the  latter  is  uncomplicated  by  any  special  condition 
like  eclampsia  or  hemorrhage,  the  chief  dangers  are  in  exhaustion  on  the  part 
of  the  mother  and  in  asphyxia  of  the  fetus ;  which  is  equivalent  to  stating  that 
the  anomalies  of  labor  which  require  forceps  are  largely  mechanical  in  character, 
and  that  therefore  whatever  imperils  the  mother  by  causing  obstruction  and 

*  Dubissy  et  Thoyer-Rosat:  "  M6d.  Moderne,"  April  12,  1S99. 

t  Black:  "Trans.  Glasgow  Obstet.  and  Gynecol.  Soc,"  vol.  i,  1S96-9,  p.  71,  appendix. 

J  "  Journ.  d'accouchements,"  Feb.  19,  1S99. 

^Ahlfeld:   "  Lehrbuch  der  Geburtshilfe,"  second  edition,  1S98,  p.  50S. 


986 


OBSTETRIC  SURGERY. 


delay  also  endangers  the  fetus  by  compression  of  the  cord,  placenta,  head,  or 
chest.  The  said  anomalies  of  labor  which  produce  these  effects  in  the  mother 
and  child  are  equivalent  to  dystocia,  maternal  or  fetal.  AVhile  it  is  seldom 
difficult  to  recognize  the  presence  of  maternal  conditions  which  demand  forceps 
intervention,  it  is  by  no  means  always  easy  to  determine  when  the  fetus  is  in 
peril.  If  the  heart-beat  either  increases  or  diminishes  steadily,  evidence  is  thereby 
furnished  of  disturbance  of  the  placental  circulation,  which  means  peril  for  the 
child.  This  behavior  of  the  heart  must  not  be  confounded  with  the  slight 
variations  w^hich  occur  during  a  uterine  contraction.  The  presence  of  meconium 
in  the  amniotic  fluid  is  dubitable  evidence  of  fetal  distress.  In  breech  presen- 
tations it  means  nothing  at  all,  for  it  is  expressed  from  the  anus  mechanically; 
and  even  in  head  presentations  its  presence  may  be  inconclusive.     I  have  fre- 


FiG.  1205. — Classification  of  Forceps  Operations.  High  Operation.  Median 
Operation  with  Complete  Retraction  of  the  Cervix  over  the  Presenting  Part. 
Median  Operation  with  only  Partial  Retraction  of  the  Cervix  over  the  Pre- 
senting Part.     Low  Operation. 


quently  seen  healthy,  unasphyxiated  children  bom  by  the  vertex  after  a  copious 
escape  of  meconium.  (Compare  Asphyxia,  Part  IX.)  As  other  evidence  of 
the  fetal  state  is  not  forthcoming,  we  must  place  our  sole  reliance  on  the  fetal 
heart. 

Special  Indications. — Maternal  exhaustion  and  fetal  asphxyia  are  the  general 
indications  for  forceps,  but  it  is  necessary  to  recapitulate  the  different  forms  of 
dystocia  which  tend  to  produce  these  conditions.  The  indications  may  proceed 
from  anomalies  of  the  expulsive  functions,  anomalies  of  resistance,  certain 
presentations  and  positions  of  the  child,  and  miscellaneous  or  non-mechanical 
complications  of  labor,  (i)  Anomalies  of  expulsive  forces:  Simple  inertia  with- 
out obstruction  may  require  forceps.  (See  Part  V.)  Protracted  labor  without 
evidence  of  obstruction  belongs  here,  but  in  the  many  cases  of  arrested  labor 


THE  FORCEPS.  987 

with  maternal  exhaustion  some  mechanical  hindrance  is  present,  and  therefore 
such  cases  belong  in  the  next  subdivision.  (2)  Anomalies  of  resistance:  Rigidity 
and  stenosis  of  the  lower  birth  tract  and  contracted  pelvis  make  up  this  category. 
If  the  natural  forces  cannot  overcome  the  obstruction,  the  forceps  is  used  unless 
contraindicated.  (3)  Fetal  dystocia:  Here  belong  such  anomalies  as  occipito- 
posterior  and  deep  transverse  cranial  positions,  face  presentations,  arrest  of 
after-coming  head  in  breech  cases,  etc.  (4)  Miscellaneous:  Here  belong  all 
severe  non-mechanical  complications  of  labor  requiring  its  immediate  ter- 
mination: Hemorrhage,  rupture  of  the  uterus,  eclampsia,  and  accidental 
complications;  severe  acute  or  chronic  disease  occurring  intermittently.  But 
the  use  of  forceps  is  not  inevitable  in  these  cases.  In  208  high,  median,  and 
low  forceps  operations,  I  found  the  most  frequent  indications  for  its  use  were 
uterine  inertia  (75  cases);  pelvic  deformity  (68  cases);  persistent  occipito- 
posterior  position  (41  cases);  and  to  hasten  labor  in  face  and  brow  presentations 
and  eclampsia. 

Prerequisites  and  Contraindications. — (i)  The  cervix  must  be  fully  dilated. 
If  the  OS  is  but  partly  open,  resort  to  forceps  will  mean  extensive  injury  to  the 
cervix  both  from  the  instrument  when  applied  and  from  the  head  when  it  trav- 
erses the  OS.  The  lesions  thus  produced  in  the  cervix  may  bleed  profusely. 
If,  however,  there  is  a  very  urgent  indication  to  end  labor  quickly,  a  narrow 
margin  of  undilated  cervix  may  be  incised  or  dilatation  may  be  completed  with 
the  fingers  as  a  preliminary  to  employing  the  forceps.  (2)  The  membranes 
must  be  ruptured.  If  the  forceps  were  applied  to  the  head  with  membranes 
intact,  the  entire  ovum  would  come  away  with  probable  detachment  of  the 
placenta.  In  delayed  rupture  it  may  be  necessary  to  incise  the  membranes 
in  order  to  apply  the  forceps.  Cases  may  arise  in  which  it  is  by  no  means  easy 
to  determine  the  condition  of  the  membranes.  Thus,  a  caput  succedaneum 
may  be  mistaken  for  a  bag  of  waters.  The  distinction  is  usually  made  by  the 
presence  or  absence  of  hair,  but  in  some  cases  it  is  necessary  to  use  a  speculum. 

(3)  The  greatest  circumference  of  the  head  must  have  passed  the  inlet  and  the 
head  must  be  fixed  in  the  pelvis.  A  head  movable  at  the  brim  constitutes  a 
contraindication  to  the  use  of  forceps.  Such  a  head  must  either  be  made  to 
engage  by  external  manipulation  or  the  labor  must  be  completed  by  version. 

(4)  Generally  speaking,  the  forceps  requires  the  presence  of  a  due  proportion 
between  the  head  and  pelvis.  The  latter  must  not  be  too  narrow.  A  living 
child  cannot  be  bom  in  a  pelvis  with  a  conjugate  of  less  than  2.95  inches  (7.5 
cm.),  and  even  in  this  degree  of  contraction  a  forceps  could  hardly  be  applied 
save  to  a  very  small  and  plastic  head.  Hence  the  conjugate  should  measure 
at  least  3  inches  (7.15  cm.).  The  forceps  should  not  be  applied  to  an  over-large 
or  hydrocephalic  head,  nor  to  an  anencephalus.  (5)  The  fetus  should  usually 
be  living  if  forceps  is  to  be  used.  In  case  of  a  dead  fetus  perforation  could  be 
more  safely  done. 

Prognosis. — Very  much  depends  upon  the  state  of  the  mother  at  the  time 
of  operation.  If  the  pulse  is  slow  and  full,  the  woman's  condition  may  be 
pronounced  good,  even  if  the  temperature  is  above  normal.  A  rapid,  low- 
tension  pulse,  on  the  other  hand,  is  somewhat  unfavorable  because  puerperal 
infection  usually  begins  in  this  manner.  Fetor  of  the  vaginal  secretions  some- 
times announces  the  existence  of  sepsis  developing  intra  partum.  Before  under- 
taking the  high  operation  in  contracted  pelves  we  should  examine  the  cervix 
in  regard  to  the  possibility  of  abnormal  stretching,  which  may  precede  a  rupture 
of  the  uterus.  Whatever  goes  wrong  in  connection  with  forceps  extraction 
will  be  laid  at  the  door  of  the  operator  unless  he  informs  the  relatives  in  advance 


988  OBSTETRIC  SURGERY. 

of  the  possibility  of  this  or  that  accident.  If  a  colleague  is  called  in  for  con- 
sultation, he  too  should  be  fully  informed  in  this  respect.  If  the  forceps  is 
applied  before  the  os  is  fully  dilated,  lacerations  of  considerable  extent  may 
occur  in  the  cervix  with  more  or  less  hemorrhage,  which  require  suture  imme- 
diately after  delivery.  Sometimes  in  the  absence  of  complete  dilatation  a 
portion  of  the  cervix  is  grasped  in  the  forceps  and  torn  oH  during  extraction. 
The  vagina  has  been  injured  in  many  ways  through  use  of  the  forceps.  The 
posterior  fornix  has  been  perforated.  In  locking  the  blades  a  portion  of  vaginal 
mucosa  may  be  included.  The  forceps  very  seldom  contributes  to  the  pro- 
duction of  a  vesico-vaginal  fistula,  which  is  generally  due  to  the  condition  for 
which  the  instrument  is  applied.  Contusions  are  caused  by  to-and-fro  move- 
ments which  are  permissible  only  when  lateral  and  of  small  excursion ;  by  forcible 
attempts  at  rotation;  and,  finally,  by  improper  traction  in  the  high  operation. 
Slipping  of  the  forceps  is  always  a  serious  accident.  It  may  result  from  incor- 
rect application  of  the  blades  or  from  uncontrolled  traction.  The  perineum 
is  always  ruptured  when  the  forceps  slips  in  the  low  operation,  and  extensive 
lacerations  of  the  vagina  may  result  from  slipping  higher  up.  The  majority 
of  cases  of  acquired  stricture  of  the  vagina  are  due  to  forceps  injuries.  Improper 
traction  is  another  source  of  maternal  traumatism.  The  high  operation  occa- 
sionally gives  rise  to  peroneal  paralysis  through  compression  of  the  lumbo- 
sacral nerve  as  it  crosses  the  pelvic  brim;  and  among  injuries  to  the  bony  pelvis 
which  thus  originate  may  be  mentioned  dislocation  of  the  coccyx,  rupture  of 
the  symphysis,  and  loosening  of  the  sacro-iliac  synchondroses.  (Page  615.)  The 
various  forms  of  traumatism  which  have  just  been  enumerated  are  almost  all 
preventable  if  the  forceps  is  properly  used.  After  forceps  delivery  there  is 
more  or  less  atony  of  the  uterus  with  the  likelihood  of  hemorrhage.  When  the 
child  is  extracted  with  forceps,  the  conditions  are  somewhat  similar  to  those  of 
precipitate  labor,  which  perhaps  explains  the  presence  of  uterine  atony  under 
these  circumstances.  For  a  consideration  of  the  forceps  injuries  of  the  child, 
see  sections  on  Fetal  Birth  Traumatisms,  Asphyxia,  etc.  (Part  IX,  pages  812 
and  823.)  I  found  in  208  forceps  operations  that  193,  or  92.34  per  cent.,  of  the 
children  were  delivered  alive;  11,  or  5.26  per  cent.,  were  still-bom;  i,  or  0.47 
per  cent.,  died  in  the  puerperium,  and  there  was  no  record  in  4  cases  (compare 
Version,  page  919).  Podalic  version  was  attempted  in  one  case  of  prolapsed 
cord. 


TECHNIQUE. 

Preparation  for  the  Operation. — The  preliminary  steps  in  a  forceps  inter- 
vention are  antisepsis  or  asepsis,  and  the  necessary  arrangement  of  the  patient 
upon  a  bed  or  an  operating  table.  The  indication  for  the  application  of  forceps 
may  arise  so  suddenly  that  but  little  time  is  available  for  preliminaries,  which 
must  therefore  be  quickly  performed.  Much  of  the  antiseptic  regimen  should 
have  been  in  force  as  part  of  the  management  of  labor  itself.  The  additional 
precautions  are  as  follows:  The  forceps  must  be  quickly  sterilized  by  boiling, 
and  if  there  is  no  time  for  this  the  forceps  must  be  "fired"  by  being  passed 
repeatedly  through  an  alcohol  flame  of  sufficient  size.  This  is  readily  accom- 
plished by  saturating  a  small  piece  of  absorbent  cotton  with  alcohol  and  allowing 
it  to  bum  on  an  ordinary  dinner-plate.  In  a  case  of  low  operation  in  a  multipara 
no  other  instrument  will  need  to  be  sterilized.  In  case  the  obstetrician  is  not 
already  prepared  to  meet  post-partum  hemorrhage  and  perform  immediate 
suture  of  extensive  lacerations, — and  this  lack  of  precaution  is,  of  course,  un- 


THE   FORCEPS.  989 

avoidable  under  many  circumstances, — all  the  material  requisite  for  such  emer- 
gencies should  be  made  ready  and  freshly  sterilized.  Vaginal  disinfection,  held 
by  many  to  be  undesirable  in  normal  labor,  is  indicated  in  forceps  extraction. 
Everything  should  be  in  readiness  to  reanimate  a  still-born  child.  The  woman 
can  be  placed  in  the  lithotomy  position  across  the  bed,  but  it  is  preferable  in  all 
operations  to  press  into  use  the  kitchen  or  other  table  and  properly  equip  it 
with  sheets,  Kelly  pad,  and  pail  for  drainage.  The  extremities  may  be  held  by 
leg-holders  (Fig.  1079),  by  the  sheet  sling,  or  if  necessary  by  assistants.  The  light 
should  fall  upon  the  vulva.  The  urine  must  be  drawn  with  a  sterile  catheter, 
a  somewhat  difficult  procedure  when  the  urethra  is  compressed  by  the  head  in 
the  excavation.  If  a  catheter  cannot  be  made  to  enter,  it  will  be  necessary  to 
forego  the  act  until  after  delivery.  A  suprapubic  examination  of  the  bladder 
should  always  be  made,  however,  because  if  the  viscus  is  distended  it  may 
simulate  that  thickening  of  the  upper  segment  of  the  uterus  which  implies  that 
the  lower  segment  is  thinned  to  the  extreme.  Such  a  condition  of  the  uterus  is 
produced  in  labor  with  contracted  pelvis,  and  is  a  threat  that  rupture  of  the 
lower  segment  may  occur.  If  the  suprapubic  tumor  disappears  when  the  urine 
is  drawn,  the  operator  need  have  no  fear  of  this  accident.  If  feces  have  accumu- 
lated in  the  rectum  since  the  beginning  of  labor,  they  should  be  removed  by 
an  enema.  In  regard  to  anesthesia,  it  is  hardly  required  in  the  low  operation  in 
multiparas.  Aside  from  this,  incomplete  anesthesia  may  be  recommended  in 
easy  extractions,  and  full  surgical  narcosis  in  all  high  and  especially  difficult 
cases.  The  anesthetic  should  be  given  by  a  colleague  who  has  had  experience. 
In  rural  practice  the  question  of  anesthesia  is  often  very  difficult  to  decide. 
There  is  no  time  to  summon  trained  assistance,  nor  can  the  administration  of 
chloroform  be  left  to  a  novice.  Under  such  circumstances  the  operator  must 
choose  between  no  anesthetic  and  partial  anesthesia.  In  these  cases  when  no 
assistant  is  at  hand  the  woman  should  be  etherized  as  deeply  as  appears  neces- 
sary, and  a  novice  quickly  instructed  in  the  use  of  the  cone  and  the  amount 
of  ether  to  be  used.  An  Allis  inhaler  is  invaluable  for  such  purposes.  From 
the  operator's  position  in  front  of  the  vulva  the  patient's  face  and  respiration 
should  be  watched.  Should  cyanosis  develop,  he  may  be  forced  to  leave  the 
forceps,  draw  out  the  patient's  tongue,  and  resort  to  the  Sylvester  method  of 
artificial  respiration. 

Action  of  the  Forceps. — The  functions  performed  by  the  forceps  comprise  (i) 
traction,  (2)  compression,  (3)  rotation,  (4)  leverage,  and  (5)  reflex  stimulation  of 
the  uterus,  or  oxytocic  action.  This  is  the  classification  in  vogue  at  the  present 
day.  Skutsch  and  a  few  other  authorities  would  eliminate  compression  and 
rotation,  so  that,  according  to  them,  the  instrument  has  but  three  distinct  func- 
tions, (i)  Traction,  which  is  applicable  to  head  and  breech  presentations  only,  and 
aids  the  natural  forces  of  the  uterus  and  abdominal  muscles  to  expel  the  child. 
(2)  Compression,  enumerated  among  the  functions  of  the  forceps,  is  admitted  to  be 
a  source  of  danger  to  the  child  and  a  meddlesome  interference  with  head-mould- 
ing. For  such  a  purpose  it  is  never  indicated,  and  its  production  is  unintentional 
— an  unavoidable  evil.  Only  enough  compression  is  indicated  for  the  blades  to 
hold  firmly.  In  extracting,  therefore,  the  instrument  should  be  grasped  near 
the  lock,  for  if  held  by  the  tips  of  the  handles  the  blades  will  be  approximated  to 
an  unnecessary  degree.  This  advice  is  especially  to  be  heeded  when  the  forceps 
is  applied  obliquely.  The  belief  was  formerly  prevalent  that  in  the  application 
of  forceps  at  the  inlet  compression  was  necessary  to  cause  the  engagement  of  the 
head.  This  originated  from  the  fact. that  as  the  head  entered  the  excavation 
the  handles  could  be  seen  to  approach  each  other,  showing  that  the  blades  were 


990  OBSTETRIC  SURGERY.' 

compressing  the  skull.  This  explanation,  however,  is  false.  The  head  following 
the  natural  descent — even  in  the  presence  of  the  forceps — presents  certain  of  its 
smaller  diameters  in  succession,  and  the  forceps  in  adapting  itself  to  them  causes 
the  approximation  of  the  handles.  While  slight  forceps  compression  may  be 
without  effect  on  the  fetal  head,  the  results  of  forceps  delivery  in  contracted 
pelves  show  that  in  most  cases  it  causes  a  great  variety  of  cranial  and  endocranial 
lesions,  to  say  nothing  of  the  part  it  plays  in  causing  asphyxia.  (3)  Rotation  is 
classed  as  a  function  of  the  forceps.  While  available  in  certain  conditions  (see 
treatment  of  occipito-posterior  positions,  page  999)  in  the  hands  of  an  expert,  it 
is  a  source  of  danger  in  other  circumstances,  menacing  the  maternal  parts  as  well 
as  the  fetus.  Many  authorities  eliminate  it  completely  from  the  list  of  functions, 
stating  that  in  the  great  majority  of  cases  rotation  is  not  an  independent  act  but 
is  brought  about  by  simple  traction.  (4)  Leverage  was  once  applied  more  freely 
than  at  present.  Its  principal  use  to-day  is  in  cases  in  which  the  head  is  advanc- 
ing with  unusual  difficulty,  when  traction  may  be  varied  by  horizontal  to-and-fro 
movements.  The  axis  of  the  forceps  should  not  depart  more  than  30  degrees 
from  the  median  plane  of  the  pelvis.  To-and-fro  movements  in  the  vertical 
direction  are  strictly  contraindicated,  as  the  maternal  passage  may  readily  be 
injured.  The  movement  of  the  forceps  in  delivering  the  head  is  not  leverage  but 
simple  traction.  (5)  The  oxytocic  or  rejiex  action  of  the  forceps  upon  the  uterus 
is  manifest  when  the  instrument  is  adjusted  to  the  fetus  after  a  period  of  uterine 
inertia.  Even  the  application  of  a  single  blade  may  be  sufficient  to  revive  uterine 
action,  and  the  uterus  in  some  cases  is  sufficiently  stimulated  to  finish  the  labor 
without  further  aid.  If  the  blades  are  cold,  the  oxytocic  action  is  still  more 
marked.  It  is  needless  to  state  that  no  one  ever  applies  forceps  solely  for  the 
sake  of  stimulating  the  uterus. 

Classification. — The  usual  classification  of  simply  high,  median,  and  low 
operations  is  defective  and  unsatisfactory  for  the  student,  since  it  confuses  two 
very  different  operations,  namely,  the  high  and  median,  and  takes  no  cognizance 
of  the  two  widely  differing  varieties  of  the  median  operation,  for  in  this  last 
variety  the  presence  of  an  undilated  or  unretracted  cervix  is  an  element  of  great 
importance  in  the  prognosis  and  treatment.  The  classification  adopted  in  this 
work  is  as  follows:  A  high  operation  is  one  in  which  the  presenting  part  is  still 
above  the  pelvic  inlet,  a  maximum  circumference,  such  as  the  occipito-frontal 
in  vertex  presentations,  not  having  passed  the  plane  of  the  inlet.  A  median 
operation  is  one  in  which  a  maximum  circumference  of  the  presenting  part  has 
passed  the  plane  of  the  pelvic  inlet.  We  should  recognize  two  important 
varieties  of  median  operation ;  first,  those  cases  in  which  the  ring  of  the  cervix  has 
only  partially  retracted  over  the  presenting  part,  the  latter  being  practically 
within  the  uterine  cavity  (Fig.  1205 ) ;  and,  second,  those  cases  in  which  complete 
retraction  of  the  cervix  over  the  presenting  part  has  occurred,  the  head  resting  in 
the  vagina  below  the  ring  of  the  cervix  (Fig.  1205).  A  low  operation  is  one  in  which 
the  presenting  part  is  at  or  in  the  vulva. 

Cephalic  Application  (Figs.  1207,  1209). — The  preferable  method  is  to 
apply  the  blades  to  the  sides  of  the  head,  thus  making  compression  in  the 
biparietal  diameter,  where  it  does  the  least  harm  and  where  the  least  room 
is  required  for  the  blades,  and  more  closely  imitating  the  natural  mechan- 
ism of  labor.  If  the  occiput  is  to  the  left  and  anterior,  the  fingers  of  the  right 
hand  are  passed  into  the  vagina  through  the  cervix  if  it  has  not  completely  re- 
tracted, and  the  left  blade  is  passed  under  the  guidance  of  the  left  hand  well  up 
into  the  space  between  the  head  and  the  left  sacro-iliac  synchondrosis,  a/nd  held 
there  by  an  assistant.     The  right  blade  is  now  passed  up  in  the  same  manner 


THE   FORCEPS. 


991 


between  the  head  and  the  right  side  of  the  pelvis  wherever  there  is  the  most  room. 
This  will  usually  be  near  the  right  sacro-iliac  synchondrosis.  It  is  then  gently 
urged  forward  along  the  right  lateral  wall  of  the  pelvis  until  it  occupies  a  posi- 
tion near  the  obturator  foramen  opposite  its  fellow  or  over  the  right  ear  of  the 
fetus.  This  may  be  done  by  means  of  the  fingers  in  the  vagina,  by  depressing  the 
handle,  rotating  it  on  its  long  axis  and  carrying  it  to  the  left  (Fig.  1207). 


Fig.  1206. — -Pelvic  Application  of  the 
Forceps,  a,  a',  Pressure  exerted  by 
lower  edge  of  the  right  blade  upon  the 
fetal  skull;  b,  b',  pressure  exerted  upon 
the  fetal  skull  by  the  upper  edge  of  the 
left  blade. 


Fig.  1207. — Cephalic  Application  of  the 
Forceps,  or  Adaptation,  b,  Left  blade. 
The  right  blade  is  introduced  opposite  the 
right  sacro-iliac  synchondrosis  at  a,  and 
carried  with  the  internal  fingers  to  a'. 


Fig. 


120S. — Pelvic   Application    of    the 
Forceps. 


Fig. 


1209. — Cephalic      Application 
Adaptation  of  the  Forceps. 


This  is  termed  adaptation  of  the  forceps  to  the  biparietal  diameter  of  the  fetal 
head.  The  second  method — namely, the  pelvic  application — is  perhaps  the  safest, 
especially  for  beginners.  If  the  cervix  is  not  completely  dilated,  it  should  be  digi- 
tally dilated,  and  care  must  be  taken,  in  guiding  the  tips  of  the  blades  through  the 
cervix  and  in  bringing  the  right  blade  forward,  that  its  concavity  is  carefully  left 
in  contact  with  the  fetal  head.     The  blades  now  hold  the  head  in  its  biparietal 


992  OBSTETRIC  SURGERY. 

diameter  and  tractions  are  begun.  Artificial  rotation  is  usually  unnecessary, 
and  should  be  avoided  by  beginners.  Traction  should  at  first  be  somewhat 
downward  and  backward  according  to  the  height  of  the  head;  the  operator 
endeavoring  to  make  traction  with  reference  to  the  axes  of  the  different  pelvic 
planes  through  which  the  head  must  pass.  If  the  head  is  in  the  upper  part  of 
the  cavity,  it  may  be  easier  to  pass  the  anterior  blade  first,  as  in  the  high 
operation. 

Pelvic  Application  {Figs.  1206,  1208). — In  this  case  the  forceps  is  applied  as  in 
the  low  operation  and  the  head  is  seized  with  one  blade  over  the  temple  and  the 
other  over  the  parietal  protuberance  of  the  opposite  side.  After  the  head  has  ro- 
tated the  forceps  is  removed  and  reapplied  to  the  sides  of  the  head.  If  the  handles 
are  loosely  held,  the  head  may  rotate  between  the  blades.  During  the  passage 
of  the  head  through  the  cervix  undue  haste  must  be  avoided  and  the  head  allowed 
to  advance  and  recede  in  imitation  of  the  natural  process  of  dilatation.  A  finger 
placed  upon  the  cervical  margin  from  time  to  time  gauges  the  amount  of  tension. 
A  finger  between  the  head  and  the  symphysis  pubis  will  also  show  how  much 
force  is  wasted  in  pulling  against  the  symphysis.  It  should  be  the  aim  of  the 
operator  to  keep  the  head  closely  applied  to  the  anterior  pelvic  wall,  but  with- 
out pressing  it  against  the  symphysis.  The  operator  should  loosen  his  grasp 
occasionally  during  a  pain  and  see  that  he  is  not  opposing  rotation.  The  direc- 
tion taken  by  the  handles  during  a  pain  may  serve  to  guide  him.  If  the  head 
is  in  the  upper  part  of  the  cavity,  the  axis- traction  forceps  should  be  preferred, 
its  skilful  use  improving  the  prognosis  for  both  mother  and  child.  If  only  the 
ordinary  forceps  is  at  hand,  good  results  can  usually  be  obtained,  and  one  hand 
may  be  used  as  a  fulcrum  in  the  manner  described  in  the  high  operation  (page 
997).  In  case  of  disproportion  in  size  between  the  head  and  the  upper  part  of 
the  pelvis,  the  Walcher  position  will  be  of  service  in  increasing  the  conjugate 
diameter  and  aiding  engagement  (page  870,  Part  X). 

Low  Operation. — In  extraction  under  the  simplest  circumstances  with  the 
head  on  the  pelvic  floor  in  the  first  vertex  position,  normal  rotation  having 
occurred,  the  technique  is  as  follows : 

Introduction  of  the  Left  Blade. — The  left  blade  is  held  with  the  left  hand  like 
a  sword  in  fencing,  with  the  thumb  at  the  inner  aspect  of  the  handle,  the  three 
last  fingers  on  the  outer  surface,  and  the  index  hooked  over  the  flange-like 
projection  at  the  distal  end  (Figs.  1210  and  121 1).  The  right  hand  assists  the 
introduction  by  guiding  the  blade  into  the  left  side  of  the  pelvis,  and  at  the 
same  time  protecting  the  maternal  and  fetal  structures  (Fig.  121 2).  This  work 
is  done  by  the  index  and  middle  fingers  introduced  into  the  left  side  of  the  pel- 
vis as  far  as  the  child's  ear  and  also  paves  the  way  for  the  forceps  between  the 
fetal  and  maternal  parts.  The  thumb,  strongly  abducted,  lies  in  front  of  the  left 
labium  majus.  The  handle  is  now  elevated  until  it  lies  opposite  the  right  groin 
and  the  tip  of  the  blade  is  introduced  into  the  vaginal  entrance  between  the 
fingers  of  the  right  hand  and  the  fetal  head,  on  the  left  side  of  the  pelvis.  The 
concave  side  of  the  blade  is,  of  course,  turned  toward  the  fetus.  The  handle  is 
now  gradually  depressed  until  it  is  almost  horizontal,  and  at  the  same  time  is 
carried  somewhat  toward  the  patient's  left.  This  movement  carries  the  tip  of  the 
forceps,  protected  by  the  two  fingers,  in  a  gentle  curve  about  the  head.  The 
border  of  the  forceps  slides  along  the  thumb,  from  which  it  derives  its  direction. 

Introduction  of  the  Right  Blade. — The  right  blade  is  introduced  in  the  same 
way,  except  that  the  movements  are  reversed  and  that  the  presence  of  the  left 
blade  makes  the  introduction  of  its  fellow  somewhat  more  difficult.  The  utmost 
gentleness  is  to  be  used  in  the  foregoing  movements;  force  is  not  allowable. 


THE   FORCEPS. 


993 


The  right  hand  now  holds  the  right  blade  while  the  first  two  fingers  of  the  left 
hand  are  introduced  into  the  right  side  of  the  pelvis  preparatory  to  the  intro- 
duction of  the  right  blade  (Fig.  12 13).  After  the  introduction  of  the  right  blade 
both  blades  are  held  for  a  moment  by  the  right  hand  while  the  left  hand  is  with- 
drawn from  the  vulva.  If  a  blade  cannot  be  introduced  at  first,  it  should  be 
withdrawn  and  a  second  effort  made.  To  facilitate  the  introduction  of  the  right 
blade  an  assistant  holds  the  handle  of  the  left  blade  down  and  to  the  side.  All 
efforts  to  introduce  the  blades  should  be  suspended  during  a  uterine  contraction. 

Locking. — After  both  blades  have  been  properly  introduced  they  should  lock 
witliout  difficulty.  This  is  accomplished  by  taking  a  handle  in  each  hand  (Fig. 
1214).  Sometimes  one  blade  is  introduced  further  than  the  other,  or  the  blades 
may  not  be  exactly  opposite  each  other,  and  slight  movements  of  adjustment 
may  be  necessary.  Difficulty  in  locking  may  indicate  that  the  head  has  been 
seized  transversely  or  obliquely,  in  which  case  the  instrument  should  be  removed 
and  reapplied  if  possible;  or  it  may  indicate  some 
complication,  e.  g.,  an  occiput  posterior  position  or 
hydrocephalus. 

Test  Traction. — The  instrument  is  now  grasped, 
the  lock  by  the  right  hand  with  the  thumb  under- 
neath and  the  middle  finger  in  the  angle  of  the  two 
blades  (Fig.  12 15).     The  left  hand  is  now  placed  ^<«fe_w 

across  the  right  at  a  right  angle,  with  the  left  index  1-  Xj" 

finger  pointing  forward  at  the  site  of  the  small  fon-  *^"^  ^ 

tanelle;  in  this  position  gentle  trial  tractions  are 


Fig.  1210. — The  Correct  Manner  of  Holding  a  Blade 
OF  the  Forceps. 


Fig.  121 1. — Incorrect  Ma.v- 
NER  OF  Holding  a  Blade 
of  THE  Forceps. 


begun.  The  finger  against  the  fetal  head  informs  us  whether  the  fetus  follows 
the  traction  and  also  detects  slipping. 

Method  of  Making  Traction. — Tractions  should  be  made  by  the  use  of  the 
arms  and  forearms,  never  by  the  weight  of  the  body  (Fig.  1216).  They  should 
be  made  in  imitation  of  nature  during  the  pains,  or,  if  these  are  absent  at  regu- 
lar intervals,  they  should  be  intermittent,  each  traction  lasting  not  more  than 
one  minute.  The  aim  should  be  to  cause  intermittent,  alternate  advance  and 
recession  of  the  head,  as  in  natural  delivery.  All  haste  and  excitement  should 
be  avoided.  During  the  intervals  between  the  tractions  the  handles  should 
be  loosened  in  order  to  limit  the  compression  of  the  fetal  head. 

Direction  of  Traction. — In  every  case  the  presenting  part  should  conform 
with  the  mechanism  of  labor.  The  traction  should  be  downward  until  the  ex- 
ternal occipital  protuberance  is  beyond  the  symphysis  pubis.  It  is  then  made 
in  a  forward  direction,  and  as  the  occiput  becomes  visible  it  is  gradually  changed 
until  the  handles  are  brought  directly  upward  (Figs.  12 17  and  1218). 

Extraction  of  the  Fetus. — When  the  small  fontanelle  is  visible,  the  left  hand 
is  removed  from  the  right  in  order  to  protect  the  perineum.  Traction  is  con- 
tinued until  the  nuchal  region  is  in  relation  with  the  pubic  arch ;  this  contact 
63 


994 


OBSTETRIC  SURGERY. 


being  determined  by  the  distance  between  it  and  the  fontanelle.  At  this 
stage  of  expulsion  the  right  hand  raises  the  handle  until  it  almost  rests  upon  the 
abdomen  and  the  head  is  born.  The  blades  are  now  separated  by  the  fingers. 
It  is  usually  advisable  to  remove  the  blades  before  final  expulsion  of  the  head 
in  order  to  lessen  the  stretching  of  the  vulva  and  the  risk  of  laceration.  The 
mechanism  of  labor  may  be  aided  during  perineal  dilatation  by  alternately 
flexing  and  extending  the  head  with  the  forceps,  the  handles  being  depressed 
just  as  the  external  occipital  protuberance  clears  the  pubic  arch  in  order  to 
produce  complete  flexion.  The  head  may  then  be  delivered  at  the  pleasure  of 
the  operator,  or  whenever  he  may  think  that  sufficient  perineal  dilatation  has 
been  secured.  When  the  head  is  about  to  be  delivered,  many  prefer  to  remove 
the  forceps  and  complete  the  delivery  without  it.  This  is  advisable  if  the 
adaptation  is  very  close;  e.  g.,  in  primiparas.  If  the  forceps  is  removed  too 
soon,  the  head  is  apt  to  slip  back  into  the  vagina.     Many  authorities  advise  the 


VAA^^^ 


Fig. 


-Introduction  of  the  Left  Blade  of  the  Forceps. 


introduction  of  the  finger  into  the  rectum  in  order  to  catch  the  child  by  the 
chin,  but  it  is  better  to  keep  the  head  in  place  when  possible  by  pressure  upon 
the  fundus  or  with  a  finger  on  each  side  of  the  coccyx  (Fig.  1218).  Intrarectal 
manipulations  are  always  to  be  avoided  as  far  as  possible,  since  they  are  not 
conducive  to  asepsis,  and  even  a  careful  use  of  this  method  may  injure  the  eyes 
of  the  child. 

General  Principles. — The  left  blade  is  applied  first  because  of  the  construc- 
tion of  the  lock.  Two  fingers  suffice  for  guiding  the  forceps  only  when  the  head 
is  very  low  and  when  the  margin  of  the  os  cannot  be  felt ;  otherwise  four  fingers 
should  be  employed.  Great  care  is  requisite  lest  the  cervix  be  mutilated  in  the 
grasp  of  the  forceps.  While  the  fingers  guide  the  forceps  in  front,  the  thumb 
performs  the  same  function  from  the  rear.  Naturally  an  attendant  could  be  of 
assistance  in  the  introduction  of  the  instrument.  All  force  is  contraindicated 
in  the  introduction  of  the  blades.  At  times  there  is  difficulty  in  locking  the 
instrument  because  the  handles  are  not  in  the  same  plane.     If  the  deviation  is 


THE  FORCEPS 


995 


slight, .they  may  be  depressed  a  Httle,  locked,  and  then  elevated;  but  if  it  is 
considerable,  it  is  evidence  that  at  least  one  blade  has  not  been  properly  intro- 
duced. In  ideal  forceps  delivery  the  blades  should  be  adapted  to  the  convexity 
of  the  parietal  bone.  Under  these  circumstances  the  handles  are  almost  per- 
pendicular to  the  sagittal  suture.  When  they  stand  apart  and  cannot  be  locked, 
an  effort  should  be  made  to  determine  which  blade  is  at  fault  by  comparing  the 
direction  of  the  handle  with  the  suture.  The  difficulty  detected,  the  blade 
must  be  readjusted,  but  it  is  not  always  necessary  to  remove  it.     If  simple 


RIGHT 


^A!^[^ 


ASSISTAUT 


Fig.    12 13. — Introduction  of  the  Right  Blade  of  the  Forceps. 


traction  with  the  hand  crosswise  over  the  lock  is  ineffective  in  moving  the  head, 
light  lateral  movements,  to-and-fro,  may  be  made.  If  this  is  unsuccessful 
traction  may  be  made  with  both  hands.  Care  must  be  taken  not  to  compress 
the  handles,  for  this  means  compression  of  the  fetal  skull.  The  direction  of  the 
traction  should  always  be  so  ordained  that  the  head  describes  movements 
identical  with  those  of  natural  labor.  We  must  not  attempt  to  use  the  forceps 
as  a  lever  at  the  time  of  the  expulsion  of  the  head ;  the  handles  should  be  raised 
during  gentle,  steady  traction.     To  apply  the  principle  of  the  lever  would  be  to 


996 


OBSTETRIC  SURGERY. 


brace  the  forceps  against  the  symphysis,  which  has  been  known  to  lacerate  the 
venous  plexuses  by  the  side  of  the  clitoris,  while  at  the  same  time  the  pos- 
terior margin  of  the  blades  may  cut  the  posterior  wall  of  the  vagina.  The  for- 
ceps occasionally  slips  or  even  comes  entirely  off.  This  may  occur  in  two 
forms:  (i)  Horizontal,  (2)  perpendicular.  In  the  former  the  blades  slip  over 
the  sinciput  or  occiput,  while  in  the  latter  the  tips  of  the  blades  are  pulled  across 
the  head  in  the  line  of  pull.  When  the  hands  are  crossed  over  the  lock  of  the 
forceps,  the  index  of  the  left  hand  is  able  to  estimate  the  relations  between  the 
pull  and  the  advance  of  the  head. 

Median  Operation. — Here,  since  rotation  of  the  head  has  not  occurred,  the 


4  ^ 


Fig.    1214. — LocKixG  the   Blades   of  the    FoRCEr's. 


Fig.    121^. — Test  Tractiox. 


Fig.  12  r6. — Method  of  .Making  Trac- 
tion IN  Anterior  Positio.vs  of  the 
Vertex. 


sagittal  suture  lying  in  an  oblique  pelvic  diameter,  there  are  two  methods  of 
operating.  First,  the  forceps  blades  may  be  applied  with  relation  to  the  sides  of 
tlie  pelvis  only, — this  is  the  pelvic  application  (Figs.  1206,  1208);  second,  they 
may  be  made  to  correspond  or  adapt  themselves  to  the  sides  of  the  fetal  head, 
— this  is  the  cephalic  application  (Figs.  1207,  1209).  The  latter  procedure 
or  adaptation  of  the  forceps  should  always  be  aimed  at,  and,  after  practice  and 
attention  to  the  mechanism  of  labor,  can  always  be  accomplished.  Cephalic 
application  secures  a  better  prognosis  for  both  mother  and  fetus  by  lessening 
the  amount  of  traction  necessary  for  extraction,  the  amount  of  pressure  to 
secure  a  firm  hold  on  the  presenting  part,  and  the  danger  of  ruptures  in  the 
genital  tract.     (Compare  Rotation,  page  1002.) 


THE  FORCEPS. 


997 


Fig.    1217. 


-Direction   of  the  Traction    in   Anterior 
Positions  of  the  Vertex. 


High  Operation. — This  operation  should  invariably  be  done  under  anesthesia. 
The  patient  is  put  in  the  ex- 
aggerated lithotomy  posi- 
tion on  a  table  of  sufficient 
height.  The  operator  is  at 
a  great  disadvantage  if  the 
level  is  low,  because  in 
making  the  necessary 
downward  traction  he 
would  be  compelled  to 
kneel.  The  buttocks 
should  be  at  the  edge  of 
the  table. 

Ordinary  Forceps. — The 
operation  is  performed  with 
the  ordinary  forceps  as  fol- 
lows: The  blades  should  be 
applied   in    the   transverse 

diameter  of  the  inlet,  therefore  at  the  occiput  and  sinciput  respectively,  for  the 

head  at  the  brim  should  usually  not  be 
seized  otherwise.  The  left  blade  is  in- 
troduced in  the  hollow  of  the  right 
hand  into  the  left  side  of  the  pelvis, 
and  adapted  by  the  aid  of  the  fingers 
to  the  fetal  head,  great  pains  being 
taken  to  prevent  the  inclusion  of  the 
thin  margin  of  the  dilated  cervix. 
The  right  blade  is  then  introduced  in 
similar  fashion  and  the  instrument  is 
locked,  strong  pressure  being  made  at 
the  same  time  against  the  perineum. 
A  trial  traction  is  first  made  to  see  if 
the  hold  is  satisfactory,  the  forceps 
being  grasped  over  the  lock  by  both 
hands,  the  right  overlapping  the  first 
two  fingers  of  the  left  (Fig.  12 15). 
While  the  left  hand  makes  traction  in 
the  direction  of  the  handle,  the  right 
presses  vertically  downward  over  the 
lock  (Fig.  1 2 19).  As  a  result  the  head 
is  drawn  past  the  brim.  The  pressure 
upon  the  lock  is  not  transmitted  to 
the  head  as  such,  but  the  riglit  hand 
forms  a  fulcrum  for  the  lock  of  the 
forceps  and  the  action  of  the  left  hand 
carries  the  handle  upward  and  the 
blades  and  fetal  head  downward  into 
the  pelvis.  Traction  should  not  be 
prolonged  over  a  minute,  and  after 
every  second  traction  an  examination 
should  be  made.  The  fetal  heart  should  also  be  watched,  and  if  fetal  death  occurs 
the  forceps  should  be  detached  and  the  head  perforated.     As  the  head  enters  the 


Fig.  1218. — Remov.'VL  of  the  Blades  of  the 
Forceps,  after  Delivery  of  the  Head. 


998 


OBSTETRIC  SURGERY. 


pelvis  the  handles  of  the  forceps  are  seen  to  rise.  An  examination  should  now 
be  made  to  determine  the  position  of  the  head  and  whether  or  not  rotation  has 
begun.  If  the  head  is  turning,  the  handles  are  seen  to  approach  each  other.  If, 
on  the  other  hand,  the  head  is  still  transverse,  careful  and  slight  anterior  rotation 
of  the  occiput  may  be  favored  with  the  forceps.  The  head  is  then  examined 
again.  As  soon  as  rotation  is  apparent,  I  advise  in  all  cases  removal  and  adapta- 
tion of  the  forceps  to  the  sides  of  the  head.  The  head  may  still  persist  in  its  high 
transverse  position,  and  in  that  case  the  blades  must  be  reapplied  obliquely.  It 
is  not  necessary  to  detach  them,  for  each  blade  controlled  by  the  finger  may  be 
slipped  along  the  head  to  the  locality  desired.  This  accomplished,  traction  is 
made,  while  at  the  same  time  the  occiput  is  rotated  forward.  The  operation  as 
described  is  very  difficult,  especially  if  the  degree  of  pelvic  contraction  is  consider- 
able. The  obstetrician  may  be  compelled  to  use  the  entire  strength  of  both  arms. 
Excessive  force,  however,  is  to  be  deprecated,  for  the  strength  of  one  man  is  the 

limit  in  this  direction.  If 
still  more  force  is  neces-  - 
sary  to  pull  the  head  into 
the  pelvis,  fracture  of  the 
cranial  bones  or  intra- 
cranial hemorrhage  will 
be  certain  to  occur.  If 
traction  is  made  in  the 
direction  of  the  handles 
without  depressing  them, 
the  force  thus  misdirected 
does  not  advance  the 
child,  but  does  make  in- 
jurious compression  on 
the  anterior  wall  of  the 
pelvis. 

Axis-traction  Forceps. 
— Since  traction  with  the 
ordinary  forceps  when  the  head  is  high  in  the  pelvis  necessarily  tends  to  pull  the 
presenting  part  against  the  s^'-mphysis,  numerous  attempts  have  been  made  to 
overcome  this  difficulty,  (i)  Some  obstetricians  use  one  hand  as  a  fulcrum  for 
the  shank  of  the  forceps  while  the  other  hand  seeks  to  tilt  the  fetal  head  into  the 
excavation,  in  which  situation  it  becomes  amenable  to  ordinary  traction  (Pajot) 
(Fig.  1 2 19).  These  manoeuvers  are  described  in  full  under  the  high  operation. 
(Page  997.)  (2)  Another  old  method  consists  in  attaching  tapes,  so-called  trac- 
tion strings,  to  the  blades  of  the  forceps,  so  that  the  traction  force  exerted  by  the 
operator  would  be  more  nearly  in  the  axis  of  the  birth  tract  (Poullet).  (3)  Still 
another  device  consists  in  using  one  arm  of  the  forceps  as  a  lever,  the  blade  being 
passed  between  the  fetal  head  and  the  symphysis,  the  latter  serving  as  a  fulcrum. 
A  tape  is  attached  to  the  blade,  and  while  one  hand  makes  the  leverage  the  other 
performs  traction  (Farabeuf  and  Vamier).  This  principle,  however,  is  best  carried 
out  by  a  traction  rod  attached  to  the  blades  of  an  ordinary' long  forceps  which  per- 
mits of  automatic  traction  and  leaves  little  or  nothing  to  the  judgment  of  the  oper- 
ator. The  credit  for  the  introduction  of  the  accessor}'  traction  rod  into  obstetrics 
belongs  wholly  to  Tamier  (Fig.  1220).  Owing  to  a  sharp  bend  in  the  shank  of  the 
rod,  the  "line  of  pull"  actually  passes  through  the  pelvic  floor,  although  traction 
in  this  imaginary  line  is  intended  only  to  carry  the  head  into  the  excavation.  An 
ordinary  long  forceps  furnished  with  a  two-armed  traction  rod  constitutes  the 


Fig.    1219. — The   Principle    of   Axis-traction    Applied 
WITH  Ordinary   Forceps.     Pajot's  Manceuver. 


THE   FORCEPS. 


999 


Fig.  I220. — The  Principle  of  the  Axis-tractio.v 
Forceps.  A,  The  blade  of  the  forceps  appHed  to 
the  fetal  head  at  the  pelvic  inlet.  B,  The  traction 
rod  at  right  angles  to  the  handle  of  the  forceps. 
A,  B,  The  direction  of  the  traction. 


axis-traction  forceps  as  originally  introduced  by  Tamier.  Numerous  modifica- 
tions of  this  principle  are  in  use  to-day.  A  further  advantage  of  Tamier's  forceps 
is  found  in  the  movable  joints  formed  at  the  insertion  of  the  traction  rod  into 
the  blades  of  the  forceps,  by  virtue  of  which  the  blades  are  left  free  to  follow 
the  natural  movements  of  the 
head  (Fig.  1221). 

Application. — The  blades 
of  the  Tarnier  forceps  are  ap- 
plied like  the  ordinary  instru- 
ment, the  traction  rods  being 
grasped  in  the  hand  alongside 
of  the  shank.  The  traction 
handle  is  then  adjusted,  and 
the  force  of  traction  is  exerted 
upon  these  handles  with  one 
or  both  hands  (Fig.  1223),  the 
handles  proper  of  the  instru- 
ment merely  serving  to  indicate 
the  direction  the  traction  is 
taking. 

It  is  necessary  for  the  suc- 
cess of  the  operation  that  the 
traction  rods  should  be  not 
more  than  half  an  inch  (1.5  cm.) 

beneath  the  handles  proper,  and  that  the  handle-bar  of  the  traction  rods  should 
be  always  in  a  horizontal  plane,  no  matter  what  the  position  of  the  blades  mav 
be  (Fig.  1222).  After  the  head  has  been  drawn  into  the  pelvis  the  handle-bar 
may  be  disconnected  and  the  fetus  extracted  with  the  handles  proper  of  the 
instrument,  or  the  entire  forceps  can  be  removed  and  further  extraction  per- 
formed with  the  ordinary 
forceps. 

Occipito-posterior  Posi- 
tions.— The  forceps  is  indi- 
cated in  occipito-posterior 
positions  only  when  the 
life  of  mother  or  child  is 
threatened.  The  applica- 
tion of  the  forceps  in  these 
cases  is  much  more  difficult 
than  in  the  physiological 
cranial  positions.  As  the 
parietal  eminences  are  seat- 
ed somewhat  more  deeply 
than  in  the  latter,  the  han- 
dles of  the  forceps  are  more 
nearly  vertical  when  the 
blades  are  applied. 
(The  treatment  of  occipito-posterior  position  is  used. 


Fig 


1221. — ^Tarnier's  Axis-traction  Forceps.    Latest 
Pattern. 


(i)  In  high  cases. 
page  545,  Part  V.) 

(2)  In  medium  cases.  Should  assistance  be  needed,  the  forceps  will  be  called 
for.  The  head  being  well  engaged,  I  am  accustomed  always  to  use  the  cephalic 
application  of  the  instrument,  namely,  adapting  the  blades  over  the  fetal  ears. 


1001) 


OBSTETRIC  SURGERY. 


When  the  forceps  is  to  be  used  as  a  rotator,  the  cephalic  in  preference  to  the 
pelvic  application  should  always  be  aimed  at,  as  the  prognosis  for  both  fetus  and 

maternal  soft  parts  is  more 
X  favorable.     Downward  trac- 

tion should  then  be  made  in 
the  proper  axis  until  the 
head  is  brought  to  the  pelvic 
floor.  If  in  its  descent  there 
is  a  tendency  on  the  part  of 
the  occiput  to  rotate  about 
the  shortest  segment  of  the 
pelvis  to  the  pubis,  this  ro- 
tation should  be  encouraged, 
but  no  marked  rotation  with 
the  forceps  as  rotator  should 
be  made  until  the  head  has 
reached  the  levator  ani  mus- 
cle. An  excellent  instru- 
ment for  this  class  of  cases 
as  well  as  the  high  ones  is  the 
last  model  of  the  Tarnier 
axis-traction  forceps.  The 
forceps  is  applied  reversed 
(inversion  of  the  forceps); 
namely,  with  the  concavity 
of  the  pelvic   curve  toward   the  posterior  part  of  the  pelvis,  and,   of  course, 

toward    the    occiput.      Leaving    the 
handles  to  take  care  of  themselves, 
\  traction   is  made   upon  the   traction 

rods  only,   and    the  swivel   connect- 

^  ,.     \  ing  these  with  the  blades  will  allow  of 

,.  ^      \  spontaneous  rotation  on  the  part  of 

;  the   head   durin^  its   descent.     Ordi- 


FiG.  1222. — Diagram  Showing  Traction  with  the 
Tarnier  Forceps.  A,  B,  In  proper,  and  X,  Y,  in 
improper  manner. —  (Ribemont-Dessaignes.) 


Fig.  1223. — Tarnier  Forceps  Applied  to 
the  Head  at  the  Inlet.  (There  should 
be  less  space  between  the  traction  rod  and 
shank  of  the  instrument.) 


Fig.    1224. — Faulty    Direction   of    Trac- 
tion  with  the  Ordinary  Forceps 


nary  fenestrated  or  solid-bladed  forceps  will  usually  answer  quite  as  well  as  the 
axis-traction  ones  (Fig.  1229). 


THE  FORCEPS. 


1001 


Double  Application  of  the  Forceps. — Another  valuable  procedure  in  high  ar- 
rest of  an  occipito-posterior  position  of  the  head,  and  which  I  frequently  make 
use  of,  is  what  is  known  as  the  double  application  of  the  forceps  or  Scanzoni's 
mauceuver. 

First  Step. — In  the  right  occipito-posterior  or  most  common  occipito-pos- 


FiG.  1225. — Double  Application  of  the 
Forceps  in  Occipito-posterior  Posi- 
tion.    First  Application. 


Fig.  1226. — Double  Application  of  the 
Forceps  in  Occipito-posterior  Posi- 
tion, Showing  Rotation  of  the  Head 
into  Transverse  Position. 


Fig.  1227. — Double  Application  of  the 
Forceps  in  Occipito-posterior  Posi- 
tion. Rotation  into  anterior  position. 
Inversion  of  the  forceps. 


Fig.  122S. — Double  Application  of  the 
Forceps  in  Occipito-posterior  Posi- 
tion. Second  Application  of  the  For- 
ceps. 


terior  position,  the  Tarnier  instrument  is  applied,  as  if  the  case  were  one  of  lett 
occipito-anterior,  namely,  with  the  pelvic  curve  of  the  forceps  looking  toward 
the  left  acetabulum  and  face  of  the  fetus.  The  blades  are  adapted  to  the  sides 
of  the  fetal  head,  the  ears  being  used  as  guides.  The  lower  or  left  blade  is  in- 
troduced first  somewhat  toward  the  hollow  of  the  sacrum.  The  right  blade  is 
then  introduced  into  the  right  side  of  the  pelvis,  and  with  the  left  hand  along- 


1002  OBSTETRIC  SURGERY. 

side  of  the  head  and  the  right  grasping  the  handle,  this  blade  is  carried  forward 
and  upward  until  it  rests  over  the  left  ear  and  opposite  the  blade  already  in- 
troduced (Fig.  1225). 

Second  Step. — Downward  traction  is  now  made  on  the  traction  handles  until 
the  head  is  brought  to  the  pelvic  floor,  and  then  anterior  rotation  of  the  occiput 
is  encouraged  until  the  sagittal  suture  comes  first  into  the  transverse  and  then 
into  the  left  oblique  pelvic  diameter.  The  forceps  are  now  found  to  be  inverted 
(Figs.  1226,  1227). 

Third  Step. — The  forceps  are  now  removed  and  reapplied  as  in  the  right 
anterior  position  of  the  occiput  (Fig.  1228). 

At  this  step  in  the  operation  I  am  accustomed  to  substitute  for  the  Tarnier 
the  ordinary  forceps,  and  complete  the  delivery  with  the  latter. 

This  method  of  treating  persistent  occipito-posterior  of  the  head  will  often 
succeed  when  one  has  failed  in  the  attempt  to  deliver  with  the  ordinary  forceps, 
or  by  first  inverting  the  Tarnier  instrument. 

(3)  In  low  cases.  In  operating,  the  usual  conditions  preparatory  to  any  for- 
ceps operation  should  be  fulfilled, and  straight,  fenestrated,  or  solid-bladed  forceps 
may  be  used.  I  have  used  both  the  fenestrated  and  the  solid-bladed  forceps,  and 
find  that  the  latter  has  certain  advantages  in  ease  of  application,  rotation,  and 
safety  to  the  maternal  soft  parts  not  possessed  by  the  former.  This  is  particularly 
true  of  difficult  cases.  The  straight  forceps  with  no  pelvic  curve,  such  as  Taylor's, 
is  not  necessary  for  the  success  of  the  operation.  When  the  occiput  is  directly 
toward  the  sacrum  and  not  opposite  either  synchondrosis,  I  am  accustomed  to 
reverse  the  forceps,  applying  it  upside-down,  so  to  speak,  with  the  lock  down  and 
pointing  to  the  occiput.  In  all  cases  adaptation  of  the  instrument  renders  the 
prognosis  more  favorable  for  mother  and  fetus.  The  forceps  being  properly 
applied,  our  object  should  be  always  to  keep  the  points  of  the  instrument  in  as 
nearly  the  center  of  the  pelvis  as  possible;  always  to  combine  rotation  with  down- 
ward traction ;  to  rotate  only  in  a  very  small  segment  of  a  circle  during  one  trac- 
tion; and,  if  uterine  contractions  are  present,  to  time  the  combined  traction  and 
rotation  with  uterine  action.  During  the  intervals  of  uterine  contractions  the 
head  should  be  held  in  the  position  obtained  in  order  to  allow  the  fetal  body  time 
to  rotate  also  and  accommodate  itself  to  the  new  position  of  the  head.  Body 
rotation  can  be  confirmed  by  abdominal  palpation.  In  my  experience  abdominal 
palpation  with  a  view  to  assist  body  rotation  is  of  little,  if  any,  advantage.  If  the 
forceps  has  not  been  reversed  after  the  occiput  has  been  rotated  into  the  anterior 
segment  of  the  pelvis,  it  will  be  necessary  to  remove  and  reapply  the  instrument 
if  delivery  is  to  be  terminated  at  this  time,  which  is  the  wisest  course  to  pursue.  If 
the  forceps  was  originally  reversed,  this  removal  and  readjustment  is,  of  course, 
unnecessary. 

Forceps  as  Rotators  (Figs.  1229,  1 230). — Much  controversy  has  arisen  over  this 
question.*  Many  authorities  claim  that  the  production  of  rotation  of  the  head  by 
instrumental  means  through  an  arc  of  180  degrees  or  even  90  degrees  is  attended 
by  so  much  danger  of  producing  lacerations  of  the  maternal  soft  parts  and  injuries 
to  the  fetal  head  or  neck  as  rarely  to  be  justifiable.  A  careful  study  of  the  subject, 
and  especially  of  the  value  of  adaptation  of  the  forceps  to  the  sides  of  the  fetal 
head,  will  convince  any  unprejudiced  operator  that  with  care  and  due  regard  to 
the  mechanism  of  labor  the  operation  is  quite  safe  for  both  mother  and  fetus. 
For  ten  years  the  author  has  been  using  straight,  fenestrated,  and  solid-bladed 
forceps  as  rotators  in  occipito-posterior  cases,  in  tardy  rotation  of  the  head  in 
vertex  and  face  presentations,  and  of  the  after-coming  head  in  breech  extractions, 
*  Compare  treatment  of  persistent  occipito-posterior  position,  page  545 


THE   FORCEPS. 


1003 


and  he  sees  no  reason  to  abandon  the  procedure.  The  requirements  for  a  good 
result  in  instrumental  rotation  are:  (i)  An  accurate  diagnosis  of  the  presenta- 
tion and  position,  obtained  under  anesthesia  and  by  the  introduction  of  the 
whole  hand  if  necessary.  (2)  The  cephalic  application  or  adaptation  of  the 
forceps  blades  to  the  side  of  the  child's  head  as  early  in  the  operation  as  pos- 
sible. (3)  A  close  imitation  of  the  normal  mechanism  of  labor  in  the  casein 
question.  (4)  The  combina- 
tion of  rotation  and  down- 
ward traction  at  one  and 
the  same  time.  (5)  Most, 
if  not  all,  of  the  rotation 
should  be  performed  after 
the  lowest  portion  of  the 
presenting  part  has  reached 
the  pelvic  floor,  as  in  spon- 
taneous rotation. 

Pelvic  Presentations. — 
Skutsch  does  not  even  dig- 
nify this  use  of  the  forceps 
with  a  paragraph  in  his  re- 
cent voluminous  work  on 
obstetric  operations.  Most 
authorities,  however,  con- 
tinue  to    recommend    it   in 

certain  conditions.  Forceps  appear  to  be  indicated  in  breech  cases  before  it  is 
possible  to  use  the  finger  or  a  fillet  to  produce  traction.  Jewett  recommends 
Olliver's  axis-traction  forceps.  If  the  breech  is  fixed  transversely  in  the  pelvis, 
the  blades  should  be  applied  over  the  trochanters.  Pressure  over  the  iliac  crests 
is  held  to  be  dangerous  and,  generally  speaking,  the  entire  procedure  is  calcu- 
lated to  cause  more  or  less  injury  to  the  fetus.     As  the  hold  cannot  be  very  firm, 


Fig. 


1229.- 


-ROTATION    OF    THE     HeAD    WITH    ORDINARY 

Forceps. 


forte  )J5 


fovtefS 


Fig.  1230. — Rotation  with  the  Forceps.  The  head  in  i  lies  transverse  in  the  pelvis, 
with  the  occiput  to  the  left.  The  forceps  is  applied  in  the  left  oblique  pelvic  diam- 
eter, and  the  head  is  rotated  (2,  3)  from  left  to  right  until  the  occiput  is  anterior  (3) 
and  the  forceps  in  the  right  oblique  pelvic  diameter. 


traction  must  be  slight  and  made  only  during  pains,  assisted  by  manual  compres- 
sion of  the  fundus.     In  my  experience  fetal  traumatisms  are  frequent. 

After-coming  Head  (Figs.  1231,  1232). — The  application  of  thefor  ceps  to  the 
after-coming  head,  formerly  much  in  vogue,  has  been  displaced  gradually  by 
various  methods  of  manual  extraction,  which,  being  capable  of  continued  im- 
provement, have  greatly  benefited  the  chances  for  survival  of  the  child.  Therefore 


1004 


OBSTETRIC  SURGERY. 


it  is  not  surprising  that  many  obstetricians  advise  doing  away  with  instru- 
mental delivery  in  these  cases  altogether.  A  majority,  however,  are  in  favor 
of  using  the  forceps  in  certain  cases,  although  the  indications  appear  to  be 
much  confused  in  most  standard  books.  The  forceps  is  indicated  in  but  a  very 
small  proportion  of  cases  of  after-coming  head.  It  is  positively  contraindicated 
when  the  head  is  above  the  brim,  for  if  manual  extraction  is  unsuccessful  the 
head  will  probably  have  to  be  perforated,  since  the  child  will  almost  certainly  be 
dead.  The  indications  for  the  forceps  are  three  in  number,  (i)  The  head  is  in 
the  excavation  with  its  long  diameter  antero-posteriorly  or  oblique,  and,  man- 
ual procedures  having  failed,  immediate  delivery  is  necessary  to  save  the  child's 
life       Experience  has  taught  me  that  now  and  then  a  fetal  life  may  be  saved. 


Fig.  1231. — The  Forceps  Applied  to  the  After-comixg   Head  in  a  Sacro-anterior 

Position. 


(2)  In  abnormal  rotation  with  the  head  extended,  the  face  in  front,  and  the  chin 
over  the  symphysis.  (3)  In  cases  in  which  prolonged  traction  on  the  trunk 
threatens  to  rupture  the  child's  neck.  Such  an  accident  might  readily  occur  in 
a  fetus  long  dead  or  in  the  presence  of  some  disease.  If  the  head  is  thus  left 
behind,  we  have  the  condition  known  as  detached  head,  to  be  described  later. 
Technique:  The  general  rule  in  vertex  anterior  cases  is  to  apply  the  forceps 
below  the  child,  which  is  lifted  upon  the  mother's  abdomen  by  the  legs,  care 
being  taken  not  to  stretch  its  neck.  The  arms  are  raised  with  the  trunk; 
the  forceps  is  applied  in  the  usual  manner,  care  being  taken  not  to  grasp  the 
cord.  Traction  should  be  made  in  the  direction  of  the  handle  until  the  chin 
appears.  Thereupon  the  nuchal  surface  of  the  child  should  be  made  to  rotate 
beneath  the  pubic   arch,  the   handles  being   turned    toward  the  mother's   ab- 


THE   FORCEPS.  1005 

domen.  I  am  accustomed  to  apply  the  forceps  above  the  child  in  occipito- 
posterior  positions,  while  others  simply  advise  that  the  instrument  be  applied 
in  the  easiest  manner  possible  and  independently  of  set  rules.  Detached  head: 
In  breech  extraction  the  head  may  be  detached  and  left  in  the  uterus  by  accident 
or  design.  In  the  former  instance  the  mishap  arises  from  decapitation  of  the 
dead  child  as  a  result  of  too  forcible  traction.  In  the  latter  case  the  head  is  left 
after  deliberate  decapitation.  If  attempts  at  manual  extraction  fail,  the  forceps 
may  be  applied,  although  cephalotripsy,  if  available,  is  the  more  rational 
course. 

Face  Presentations  (Fig.  1233). — The  general  principle  in  the  management 
of  these  cases  is  expectancy.  There  is  no  indication,  from  the  position  alone, 
to  apply  the  forceps.    Only  when  the  life  of  mother  or  child  is  threatened  should 


""^ft.. 


Fig.   1232. — The  Forceps  Applied  to  the  After-coming  Head  in  a  Sacro-posterior 

Position. 

we  resort  to  instrumental  intervention.  In  mento-anterior  positions  with  the 
face  in  the  antero-posterior  diameter,  extraction  should  be  easily  effected.  The 
handle  of  the  forceps  should  be  higher  than  in  cranial  occipito-posterior  posi- 
tions. If  this  point  is  overlooked,  the  tips  of  the  forceps  may  compress  the  fetal 
neck.  Traction  should  be  made  in  the  direction  of  the  handle  until  the  chin  is 
born  beneath  the  symphysis,  the  child's  throat  being  in  contact  with  the  liga- 
nientum  arcuatum.  The  handle  is  now  turned  strongly  upward  toward  the 
mother's  abdomen,  and  the  face,  brow,  vertex,  and  occiput  are  born  in  suc- 
cession over  the  perineum.  The  forceps  carries  the  head  from  its  position  of 
extreme  extension  to  one  of  flexion.  As  the  handle  of  the  instrument  arrives 
at  the  abdomen  the  task  is  finished  and  the  forceps  should  be  detached.  If 
the  mento-anterior  face  is  in  an  oblique  diameter,  the  forceps  is  applied  trans- 


1006 


OBSTETRIC  SURGERY. 


versely  unless  the  obliquity  is  extreme.  Then,  under  traction,  the  head  rotates 
normally.  The  oblique  application  is  not  contraindicated.  In  the  second 
facial  position,  chin  to  the  right,  the  left  blade  should  be  applied  in  front;  in 
the  second,  chin  to  left,  the  right  blade  goes  in  front.  In  a  deep  transverse 
facial  position  the  forceps  is  applied  obliquely  with  the  pelvic  curve  turned 
toward  the  chin.  The  conditions  are  analogous  to  forceps  delivery  in  deep 
transverse  head  (page  1006).  Mento-posterior  position:  In  mento-posterior 
positions  with  the  indication  for  immediate  extraction  the  forceps  is  of  no 
service  and  the  head  must  be  perforated.  Scanzoni's  method  of  rotating 
the  head  with  the  forceps  must  be  condemned.  Some  obstetricians  hold  that 
the  mancEUver  may  be  feasible  in  some  cases  in  the  hands  of  an  expert,  but  it  is 
rarely  safe.  The  head  is  grasped  at  the  sides,  the  forceps  being  applied  obliquely 
with  the  concavity  of  the  pelvic  curve  directed  in  front.  The  face  is  now  rotated 
into  the  transverse  position.    The  blades  are  then  detached  and  reapplied  in  the 


Fig.   1233. — Forceps  in  Face  Presentation.     Mento-anterior  Position. 


manner  described  for  deep  transverse  face.  (Compare  Treatment  of  Mento- 
posterior cases.  Part  V,  page  550.) 

Brow  Presentation. — The  forceps  should  be  applied  as  in  bregma  and  face 
presentations  with  the  handles  relatively  high  in  order  to  obtain  the  best  possible 
grasp  of  the  head.  In  making  traction  we  should  always  be  controlled  by  knowl- 
edge of  the  mechanism  in  these  cases.  We  should  pull  in  the  direction  of  the 
handles  until  the  root  of  the  nose  arrives  at  the  ligamentum  arcuatum.  The 
handles  are  then  lifted  well  up  and  carried  to  the  mother's  abdomen,  while  the 
vertex  and  occiput  are  bom  over  the  perineum.  The  handles  are  then  brought 
down  again,  pressure  being  made  at  the  same  time  with  the  hand  on  the  brow, 
and  the  remainder  of  the  face  is  delivered.  There  is  therefore  an  analogy,  from 
the  standpoint  of  forceps  delivery,  between  brow  and  occipito-posterior  positions. 

Deep  Transverse  Head. — There  is  no  indication  for  the  use  of  instruments 
in  this  position  save  immediate  danger  to  mother  or  child.  The  forceps,  in  order 
to  grasp  the  head  over  the  parietal  eminences,  would  have  to  be  without  pelvic 


THE  SLING  OR  SOFT   FILLET. 


1007 


curve  (straight  forceps).  If  the  ordinary  instrument  is  used,  the  blades  must  be 
applied  in  an  oblique  diameter  and  the  concavity  of  the  pelvic  curve  must  be 
turned  toward  the  occiput.  The  latter  is  then  rotated  forward  till  the  concavity 
of  the  forceps  is  turned  to  the  anterior  pelvic  wall.  If  the  occiput  was  on  the 
left  side  of  the  pelvis,  it  rotates  into  the  L.  0.  A.,  and  vice  versa.  When  the 
head  is  ready  for  extraction,  the  concavity  of  the  side  of  the  forceps  must  corre- 
spond with  the  curvature  of  the  pelvic  canal.  Occasionally  it  happens  that  the 
mere  locking  of  the  forceps  produces  some  rotation  forward  of  the  occiput,  so  that 
when  the  blades  are  brought  into  the  transverse  diameter  the  sagittal  suture 
is  found  to  be  in  the  antero-posterior  diameter.  In  this  case  as  soon  as  the 
neck  of  the  child  reaches  the  pubic  arch  the  handle  is  brought  upright  in  the  cus- 
tomary manner.  If  the  small  fontanelle  is  not  brought  to  the  middle  line  when 
the  blades  are  in  the  transverse  diameter,  extraction  must  be  accompanied  by  a 
slight  degree  of  rotation. 


VIII.  THE  SLING  OR  SOFT  FILLET. 

The  sling,  soft  fillet,  noose,  fillet,  or  loop,  as  it  is  variously  called,  is  occasion- 
ally used  in  obstetric  manipulations,  and  could,  I  am  certain,  with  advantage  be 
much  more  frequently  employed. 

Indications  and  Actions. — The  sling  is  used  chiefly  in  cases  of  high  arrest  of 
the  breech,  and  it  should  be  noted  that  it  has  five 
distinct  uses:  viz.,  (i)  As  a  tractor;  (2)  to  prevent 
recession  of  the  presenting  part;  (3)  to  facilitate 
manipulations  by  drawing  the  presenting  part  to 
one  side;  (4)  to  serve  as  an  accessory  when  the 
simultaneous  employment  of  both  hands  is  for- 
bidden by  lack  of  space;  (5)  to  prevent  extension 
of  the  arm  or  arms. 

Material  and  Carriers. — A  yard  of  two-inch 
gauze  bandage  boiled  and  moistened  with  i  per 
cent,  lysol  solution  answers  very  well  for  a  soft 
fillet.  Another  excellent  fillet  is  a  yard  of  one- 
fourth-inch  rubber  tubing  through  which  a  tape 
is  passed,  stitched  to  the  side  of  the  tubing,  and 
allowed  to  project  six  inches  at  both  extremities. 
In  many  cases  fillets  can  be  passed  over  the  thigh 
with  the  index  finger.  This  will  often  necessitate 
the  passage  of  the  whole  hand  into  the  vagina.  A 
ready  method  is  to  take  a  No.  16  English  catheter 
with  stylet  in  place,  and  bend  the  end  of  the  cath- 
eter into  a  hook  of  the  shape  of  the  ordinary 
blunt  hook  (Fig.  1109).  A  doubled  piece  of  tape 
or  bobbin  is  threaded  into  the  edge  of  the  catheter 
by  means  of  the  stylet,  and  the  hook  with  the  tape 
is  passed  over  the  thigh  in  the  most  convenient 

manner.  The  tape  is  then  caught  with  two  fingers  or  a  pair  of  dressing  forceps  and 
the  catheter  withdrawn.  The  tape  is  now  used  as  a  sling  to  draw  the  desired  fillet 
into  position  Blunt  hooks  are  often  perforated  with  an  eye  at  the  extremity  and 
used  instead  of  the  catheter.     A  fillet  carrier  or  porte-fillet  is  a  special  instrument 


Fig.    1234. 

JUSTING 

Foot. 


Method    of    Ad- 
L     Sling    to    the 


1008 


OBSTETRIC  SURGERY. 


made  for  the  purpose.  It  is  on  the  principle  of  Bellocq's  cannula  used  by  sur- 
geons in  drawing  up  a  plug  into  the  posterior  nares.  It  is  curved  like  the  ob- 
stetric blunt  hook  and  has  a  long  piece  of  whalebone  running  through  the  canal. 
In  Pelvic  Presentation. — Here  the  soft  fillet  is  used  as  a  tractor.  In  low  arrest 
of  the  breech  the  hand  usually  proves  the  best  tractor,  and  even  in  high  arrest 
it  is  sometimes  possible  to  pass  a  finger  or  several  fingers  into  the  flexure  of 
the  groin;  when  the  hand  cannot  be  used,  we  resort  to  the  soft  fillet  or  forceps. 
Traction  with  a  single  or  double  fillet,  in  impacted  pelvic  presentations,  is  a  valu- 
able means  of  extraction,  much  safer  in  the  hands  of  most  operators  than  the 
blunt  hook  or  forceps,  and  a  method  of  delivery,  I  believe,  too  seldom  resorted 

to.  Often  in  tardy  breech  ex- 
pulsion the  delay  is  caused  by 
flexion  of  the  fetal  pelvis  upon 
the  trunk,  and  perhaps  by  ex- 
tension of  the  legs  alongside 
of  or  above  the  fetal  head. 
Traction  on  one  or  both  groins 
extends  the  pelvis,  draws 
down  the  feet,  and  thus  ren- 
ders the  passage  of  the  breech 
through  the  parturient  canal 
easier,  provided  no  great  dis- 
proportion exists  between 
fetus  and  maternal  pelvis. 
Sling  to  one  groin:  When  a 
single  sling  is  used,  it  should 
encircle  by  preference  the  an- 
terior or  lower  thigh,  and  in 
the  majority  of  cases  a  single 
sling  is  sufficient.  ~  I  have  in 
difficult  cases  combined  the 
sling  to  the  anterior  groin  and 
the  protected  blunt  hook  to 
the  posterior  (Fig.  1177). 
Sling  to  both  groins:  Unless 
too  great  difficulty  is  encoun- 
tered it  is  preferable  to  pass  a 
soft  fillet  over  both  groins,  as 
by  so  doing  the  force  of  trac- 
tion is  more  evenly  distribut- 
ed and  there  is  less  danger  of 
injury  to  the  soft  parts  and 
the  heads  of  the  femurs.  Sling  encirchng  fetal  pelvis:  Although  it  is  difficult  and 
often  impossible  to  apply  a  fillet  encircling  the  fetal  pelvis,  with  the  ends  passing 
down  between  the  thighs,  it  is  the  safest  and  most  efficient  way.  The  English  ad- 
vise the  use  of  a  soft  handkerchief  for  the  purpose,  but  a  piece  of  four-inch  gauze 
bandage  a  yard  long,  boiled  and  lubricated  with  a  i  per  cent,  lysol  solution,  an- 
swers better.  A.  knot  is  tied  at  each  end,  and  one  knot  is  carried  with  the  fingers-, 
an  English  catheter,  or  a  porte-fillet,  on  one  groin  from  without  inward,  until  the 
knot  can  be  reached  between  the  thighs  and  drawn  down.  In  like  manner  the 
other  end  of  the  fillet  is  passed  over  the  opposite  groin  from  without  inward,  thus 
bringing  both  ends  of  the  fillet  down  between  the  thighs.    With  the  whole  hand  if 


Fig. 


1235. — Adjusting  .\   Slixg  to  the  Left  Ante- 
rior Leg 


THE   BLUNT   HOOK.  1009 

necessary  in  the  vagina,  the  center  of  the  fillet  is  adjusted  up  over  the  buttocks  and 
around  the  fetal  pelvis  by  an  upward  movement  of  the  internal  hand  and  down- 
ward traction  on  the  two  ends  of  the  fillet  with  the  external  hand.  The  fillet  is 
thus  made  to  make  traction  on  the  external  circumference  of  the  pelvis,  thus  re- 
lieving the  groins  from  the  dangerous  traction  exerted  by  the  other  forms  of  fillet. 
It  is  not  always  possible  to  adjust  this  sling  after  the  breech  is  firmly  impacted  in 
the  pelvis,  and  even  at  the  pelvic  inlet  it  is  at  first  difficult  unless  it  has  been 
repeatedly  practised  on  the  puppet  and  pelvis  or  manikin  (Fig.  1176). 

In  Version. — It  is  especially  in  complicated  internal  version  that  the  soft  fillet 
finds  its  chief  use  (page  935). 

Placenta  Praevia. — It  occasionally  happens  that  a  combined  or  internal  ver- 
sion is  performed  in  placenta  praevia;  one  leg  is  brought  down  and  the  half 
breech  used  to  tampon  the  partially  dilated  cervix.  Under  such  circumstances 
the  version  is  not  always  followed  by  immediate  extraction,  and  in  the  mean 
while  a  soft  sling  to  the  prolapsed  leg  is  a  convenient  way  to  keep  up  pressure 
■on  the  placenta  and  prevent  recession  of  the  leg  (Fig.  1080). 

Prolapse  of  the  Cord. — In  like  manner  the  sling  may  be  used  after  version  in 
prolapse  of  the  cord  to  hold  the  half  breech  temporarily  in  the  partiall}^  dilated 
cervix  and  thus  prevent  recurrence  of  the  prolapse. 

In  Prolapse  of  an  Arm  in  Shoulder  Presentation  (Fig.  11 26). — In  cases  of  ver- 
sion in  shoulder  presentation  complicated  by  prolapse  of  an  arm  the  sling  is  ap- 
plied to  the  wrist  and  used  to  draw  the  arm  forward  and  backward,  thus  making 
room  for  the  passage  of  the  hand  into  the  uterus,  and  afterward  to  prevent 
extension  of  the  arm  and  subsequent  difficulty  in  extracting  the  head.  In  all 
cases  care  should  be  taken  not  to  injure  a  fetal  member  by  tying  the  sling  too 
tightly  or  making  traction  too  forcibly.  Sawing  movements  should  be  avoided, 
since  they  may  cause  extensive  laceration  of  the  fetal  parts.  When  the  pre- 
senting part  is  high  and  difficult  to  reach,  it  is  often  convenient  to  pass  the  loop 
over  the  operator's  arm.  It  may  then  be  pushed  up  by  a  pair  of  long  forceps 
or  some  similar  instrument  (Fig.  11 28). 

Combined  Manipulation  in  Version. — When  there  is  difficulty  in  turning  in 
internal  podalic  version,  in  cephalic  or  shoulder  presentation,  by  reason  of  the 
grasp  of  the  uterus  over  the  fetus,  success  may  sometimes  be  obtained  by  attach- 
ing a  sling  to  a  foot  and  making  traction  on  the  foot  by  means  of  the  end  of  the 
sling  outside  of  the  vagina,  and  at  the  same  time,  with  the  other  hand  in  the 
vagina,  making  upward  pressure  upon  the  head  or  shoulder.  Skilled  assistance, 
by  depressing  the  breech  and  pushing  up  the  head  externally,  will  greatly  aid  the 
rnanoeuver  (Fig.  11 29). 

Prophylactic  Sling  inversion. — It  has  been  proposed,  as  a  preliminary  to  in- 
ternal podalic  version,  to  fasten  a  sling  on  one  or  both  fetal  wrists  in  iitero,  the 
object  being  at  all  stages  of  the  operation  thus  to  keep  both  forearms  below  the 
chin  and  prevent  extension  of  the  arms.  The  procedure  is  a  dangerous  and 
an  unnecessary  one,  for,  although  theoretically  correct,  the  manipulation  of  the 
fetal  thorax  and  umbilical  cord  will  in  many  cases  disturb  the  equilibrium  of  the 
fetal  circulation  and  cause  asphyxia  by  premature  respiration  within  the  uterus. 


IX.   THE  BLUNT  HOOK. 

The  blunt  hook,  made  entirely  of  metal  for  aseptic  reasons,  about  twelve 
inches  long  and  with  a  semicircular  curve  at  the  end  forming  a  hook  the  diameter 
64 


1010 


OBSTETRIC  SURGERY. 


of  which  is  two  inches,  is  still  a  valuable  and  useful  instrument  in  operative 
obstetrics  (Fig.  1236). 

Uses. — The  use  of  the  blunt  hook  should  be  confined  principally,  if  not  en- 
tirely, to  the  extraction  of  the  dead  fetus.  It  may  be  passed  over  the  groin  in 
breech  presentation  for  traction,  then  over  the  brim  of  the  fetal  pelvis,  and  hooked 
into  the  ribs  or  over  the  shoulders  or  a  humerus  in  difficult  shoulder  extraction. 
In  the  case  of  a  living  fetus  the  blunt  liook  should  be  used  with  the  greatest  care, 
if  at  all ;  the  soft  fillet  or  digital  traction  is  usually  to  be  preferred.  On  the  living 
its  use  is  principally  confined  to  traction  on  the  anterior  or  pos- 
terior groin  or  both  in  difficult  breech  extractions.  It  is  not 
desirable  to  use  this  instrument  on  a  living  fetus  unless  all 
other  methods  of  extraction  fail,  by  reason  of  the  injury  to  the 
fetal  soft  parts  and  to  the  head  of  the  femur  liable  to  follow  its 
use.  To  avoid  injury  to  the  skin  of  the  groin,  the  writer  is 
accustomed  to  slip  a  piece  of  tightly  fitting  rubber  tubing  over 
the  hook  and  shank  of  the  instrument,  sterilizing  the  whole 
before  use.  Wrapping  the  hook  and  several '  inches  of  the 
shank  with  a  one-inch  gauze  bandage  also  answers  very  well 
in  the  absence  of  the  rubber  tubing.  The  blunt  hook,  thus 
protected,  carefully  and  judiciously  used,  becomes  a  valuable 
instrument  in  impacted  breech  cases,  but  in  the  hands  of  the 
careless  and  inexperienced  in  its  use  it  is  capable  of  much  in- 
jury to  the  fetus.  It  is  advisable  to  pass  the  hook  over  the 
anterior  thigh  in  breech  cases,  since  this  thigh  is  lowest  and 
most  readily  reached.  It  is  passed  up  lying  flat  against  the 
thigh,  with  the  hook  pointing  toward  the  anterior  surface  of 
the  fetal  ellipse  until  opposite  the  groin,  the  hook  then  being 
passed  over  the. flexure  of  the  thigh,  care  being  taken  to  have 
the  hook  descend  between  the  thighs  and  not  catch  on  one 
thigh,  to  avoid  damage  to  the  femur  and  the  femoral  vessels. 
The  proper  adjustment  is  secured  by  digital  palpation  between 
the  thighs. 


Fig.      1236. — The 
Blunt  Hook. 


X.  THE  CROTCHET. 

The  crotchet  was  an  instrument  which  in  the  days  of  cranio- 
tomy was  used  for  the  extraction  of  the  mutilated  head  after 
the  vault  of  the  skull  had  been  removed  piecemeal  with  the 
craniotomy  forceps.  It  is  practically  a  sharp  hook  about  f  inch 
in  length  with  a  suitable  handle  for  traction.  The  instrument 
is  now  obsolete,  but  may  be  found  among  the  collections  of 
instruments  in  the  older  maternity  hospitals,  and  upon  inquiry 
at  the  three  largest  instrument-makers  in  New  York  I  fotmd  the  instrument  was 
at  first  unknown,  until  reference  was  made  to  an  illustrated  price-list.  Occasion- 
ally in  the  past  ten  years  I  have  used  the  instrument  in  the  extraction  of  a  dead 
fetus,  when  fixed  in  an  axilla,  between  the  ribs,  or  any  available  part  of  the  body. 
The  blunt  hook  may  be  used  in  the  same  way.  Originally,  for  extraction  after 
perforation  or  craniotomy  the  hook  was  passed  into  the  interior  of  the  skull  and 
moved  about  until  a  firm  hold  was  secured  upon  the  bones  of  the  vault  or  sides  of 
the  skull.     It  was  not  intended,  nor  was  it  possible,  to  fix  it  in  the  foramen  mag- 


CESAREAN  SECTION.  1011 

num,  as  is  so  often  stated  in  the  text-books.     Quite  another  instrument,  namely, 
the  vertebral  hook,  was  used  for  that  purpose. 


XI.    EXTRACTION  OF  THE  FETUS  MUTILATED  BY 
EMBRYOTOMY. 

Extraction  of  the  fetus  after  (i)  perforation  (page  944)  1(2)  cranioclasis  (page 
947)1  (3)  cephalotripsy  (page  951);  (4)  decapitation  (page  955);  (5)  eviscera- 
tion (page  960);  (6)  cleidotomy  (page  961);  and  (7)  spondylotomy  (page  963), 
is  described  under  the  heads  of  these  operations  as  above  indicated. 


XII.   C^ESAREAN  SECTION. 

Definition, — The  term  Caesarean  section  is  applied  to  the  operation  also  called, 
in  accordance  with  modern  ideas  of  nomenclature,  laparo-hysterotomy,  which 
consists  in  the  extraction  of  the  child  through  an  abdominal  and  a  uterine  in- 
cision. 

Historical. — The  derivation  of  the  term  Cesarean  is  wrapped  in  some  obscurity,  but 
the  best  evidence  seems  to  connect  it  with  the  name  Csesar,  which  in  turn  seems  very  hkely 
to  have  its  origin  in  the  root  of  the  verb  "caedere,"  to  cut.  A  form  of  the  operation  seems 
to  have  been  known  early  in  the  history  of  Rome,  and  it  is  recorded  that  an  ancient  ruler 
of  that  city,  Numa  Pompilius,  caused  a  law  to  be  enacted  requiring  the  operation  on  recently 
dead  women  far  advanced  in  pregnancy  so  that  mother  and  child  might  be  interred  sepa- 
rately. Certain  tribes  have  likewise  made  it  customary  to  remove  the  child  even  when  there 
was  no  thought  of  its  survival.  Medieeval  records  of  the  operation  are  few  and  unsatis- 
factory, and  of  no  great  interest  except  historically.  A  case  is  recorded  from  Venetian 
sources  in  1491,  and  somewhat  later  a  Swiss  peasant  is  said  to  have  done  the  operation 
upon  his  own  wife,  though  certainly  not  before  death.  Somewhat  later,  apparently,  the 
possibility  of  doing  the  operation  upon  the  living  began  to  be  discussed,  and  the  question 
of  how  much  risk  the  mother  should  be  subjected  to  in  order  to  save  the  child  began  to 
be  argued.  The  first  operation  upon  the  living  appears  to  have  been  done  in  1610  by 
Trautman,  though  it  is  really  only  since  the  advent  of  antisepsis  that  the  operation  can 
'  be  said  to  have  assumed  a  recognized  and  important  place  among  obstetrical  pro- 
cedures. The  consensus  of  opinion  always  has  been,  and  still  is,  that  the  life  of  the  mother 
is  more  important  than  that  of  the  child,  and  that  the  former  should  not  be  subjected  to 
chances  the  favorable  results  of  which  accrue  to  a  great  extent  to  the  latter.  The  field  for 
Caesarean  section  is  therefore  limited,  though  under  modem  conditions,  with  a  proper 
selection  of  cases,  the  risks  to  the  mother  have  been  very  greatly  diminished  and  the  opera- 
tion has,  in  many  instances,  come  into  competition  with  embryotomy  and  symphyseotomy. 
The  doctrine  of  the  Roman  Catholic  Church  has  always  been  that  it  is  a  mortal  sin  to  com- 
pass the  death  of  the  child  in  order  to  extract  it,  and  among  adherents  of  that  faith  this 
fact  may  sometimes  have  a  bearing  upon  the  choice  of  this  operation  in  preference  to 
embryotomy.  The  operation  of  embryotomy  upon  a  living  child  at  or  near  term  is  the  most 
revolting  thing  which  a  medical  man  can  be  called  upon  to  do,  and  whenever  there  is  a 
reasonable  prospect  that  the  abdomen  can  be  opened  and  the  child  thus  removed  with  no 
greater  risk  to  the  mother  than  is  incurred  by  any  procedure  which  involves  the  sacrifice  of 
the  child,  Caesarean  section  may  be  undertaken.  The  earlier  writers  in  the  last  half  of  the 
nineteenth  century  spoke  very  disparagingly  of  Caesarean  section  and  looked  upon  it  as  a 
last  resort  in  desperate  cases,  a  fact  which  explains  to  a  great  degree  their  almost  uniform 
lack  of  success.  When  antisepsis  came  in,  and  when  cases  began  to  be  properly  selected, 
the  proportion  of  successes  began  to  rise,  until  at  present  it  has  reached  a  comparatively 
encouraging  figure.  The  few  instances  in  history  in  which  prominent  men  are  said  to  have 
been  brought  into  the  world  by  the  abdominal  route  are  not  authenticated,  and  in  all  it  is 
uncertain  whether  the  mother  was  alive  or  dead  at  the  time  of  the  alleged  operation. 

Indications. — The  indications  for  this  operation  are  of  two  kinds — positive 
and  relative;  the  former  of  which  may  be  disposed  of  in  a  few  words.  Caesa- 
rean   section  is  positively  indicated  when  the    maternal   or  fetal  dystocia  is 


1012  OBSTETRIC  SURGERY. 

so  great  that  it  is  impossible  to  remove  the  fetus  even  after  embryo- 
tomy. The  relative  indications  for  the  operation  are  not  so  clearly  marked. 
When  it  is  evident  that  embryotomy  can  be  done  successfully  and  without 
great  risk  to  the  mother,  the  question  in  the  presence  of  a  dead  child  is 
easily  decided,  but  if  the  child  is  alive  the  proper  course  is  not  so  clear.  The 
good  results  which  have  recently  followed  Caesarean  section  have  led  many 
operators  to  consider  that  a  conjugate  of  3  inches  (7.62  cm.)  with  the  child 
living,  and  2.76  inches  (7  cm.)  with  the  child  dead,  requires  the  operation. 
It  is  to  be  remembered  that  in  cases  in  which  the  difficulty  is  due  to  a  fiat  rather 
than  a  generally  contracted  pelvis,  a  shorter  conjugate  will  suffice  to  effect 
delivery  through  the  natural  passages.  In  1887  Lusk,  of  New  York,  declared 
that  embryotomy  in  a  greatly  contracted  pelvis  was  as  dangerous  to  the  mother 
as  Cassarean  section,  and  that  since  the  former  operation  always  sacrifices  the 
child,  we  should  not  wait  too  long  before  resorting  to  the  latter  when  other  means 
of  delivery  fail.  These  views  have  been  substantiated  by  many  later  observers. 
We. should  remember  that  in  rachitic  dwarfs  the  indication  for  Cesarean  section 
is  practically  always  present  unless  labor  is  induced  at  a  very  early  date  in  the 
pregnancy,  and  if  such  patients  are  met  with  later  we  must  anticipate  the  neces- 
sity of  the  operation.  As  a  rule,  Csesarean  section  should  be  done  at  term,  but  it  is 
not  necessary  to  wait  for  labor  to  begin.  A  point  in  favor  of  the  Caesarean  opera- 
tion is  that  by  it  measures  can  be  taken  to  prevent  future  conceptions  by  tying 
and  dividing  the  Fallopian  tubes.  While  pelvic  deformity  is  the  commonest 
condition  which  requires  this  mode  of  delivery,  carcinoma  of  the  cervix  pre- 
venting dilatation  and  pelvic  tumors  of  almost  any  kind  may  be  the  cause 
of  the  dystocia.  Eclampsia  and  placenta  praevia  have  sometimes  been  put 
down  as  conditions  which  may  occasionally  demand  Caesarean  section;  how- 
ever, while  it  is  conceivable  that  it  might  be  advisable  to  do  the  operation 
in  eclampsia,  it  is  safe  to  say  that  placenta  praevia  will  rarely  demand 
it.  The  decision  to  operate  must  always  depend  to  some  extent  upon 
the  characteristics  of  individual  cases,  and  experience  alone  will  enable  us  to 
draw  uniformly  just  conclusions,  but  the  figures  given  above — a  conjugate  of 
3  inches  (7.62  cm.)  for  a  living  child  and  2.5  inches  (6.35  cm.)  for  a  dead  one — may 
be  taken  as  correct  in  indicating  the  operation,  barring  special  and  unusual  con- 
ditions. In  cases  in  which  the  conjugate  is  over  3  inches  ( 7.62  cm.),  but  still  some- 
what or  considerably  under  normal,  judgment  is  required  to  avoid  extremes  and 
decide  between  the  comparative  advantages  of  premature  labor  and  symphyse- 
otomy. We  must  not  wait  until  the  patient  is  so  exhausted  from  shock, 
hemorrhage,  or  sepsis  from  absorption  that  she  has  no  recuperative  powers  left. 
When  we  have  concluded  to  operate,  we  have  still  to  choose  between  Caesarean 
section  and  the  so-called  Porro  modification.  Cameron  has  made  about  fifty 
patients  sterile  by  dividing  the  Fallopian  tubes  between  ligatures,  and  has  had  no 
bad  results  after  the  operation.  This  procedure  must  also  be  considered,  since  its 
success  naturally  removes  a  great  future  danger,  and  the  theoretical  danger  of 
subsequent  pelvic  hematocele  has  not  been  encountered. 

Prognosis. — The  prognosis  in  Cesarean  section  is  yearly  improving. 
I  am  unable,  however,  to  give  statistics  that  will  cover  all  the  different  varie- 
ties of  cases.  So  long  as  the  results  of  operations  performed  in  well-equipped 
operating  rooms,  with  every  convenience  at  hand,  are  included  in  the  results 
obtained  under  unfavorable  environment  and  with  faulty  assistance,  so  long 
will  the  statistics  be  misleading.  We  can  state,  however,  that  when  the  en- 
vironment is  favorable,  when  conveniences  and  competent  assistants  are  at 
hand,  when  the  mother  is  in  good  condition  and  has  not  been  infected  by  repeated 


CESAREAN   SECTION. 


1013 


examinations  and  unsuccessful  attempts  at  delivery,  and  when  the  fetus  is 
still  strong  and  healthy  in  the  uterus,  the  danger  of  Cesarean  section  to  the 
mother  is  almost  nil,  and  we  can  assure  the  patient  and  her  family  that  the 
child  will  almost  certainly  survive. 


OPERATION. 

Preparation  of  the  Patient. — The  preparation  of  the  patient,  emergencies  ex- 
cepted, is  exactly  the  same  as  for  any  other  laparotomy,  with  the  additional  pre- 
caution of  cleansing  the  vagina  by  scrubbing  and  the  use  of  alcohol  and  bichloride- 
of-mercury  or  lysol  solution.  In  an  emergency  as  much  as  possible  should  be 
done,  and  we  can  at  least  be  sure  of  sterile  hands,  instruments,  and  dress- 
ings. Provision  must  be  made 
for  liberating  the  fetal  head 
from  below  in  case  it  has  be- 
come firmly  engaged  in  the 
pelvis. 

Instruments. — The  instru- 
ments required  are  few  and 
simple.  Plenty  of  artery 
clamps  should  be-  at  hand, 
and  these,  in  addition  to  a 
knife,  scissors,  dissecting  for- 
ceps, needles,  and  needle  for- 
ceps, are  all  that  are  required. 
Silk  and  catgut  ligatures  must 
be  ready,  and  a  number  of 
good-sized  needles  already 
threaded  with  catgut  for  use 
in  closing  the  uterine  incision. 
The  bladder  should  be  emp- 
tied shortly  before  the  opera- 
tion is  begun.  Four  assist- 
ants besides  the  operator  are 
necessary — one  to  give  the 
anesthetic,  one  to  assist  the 
operator  at  the  wound,  one  to 
hand  the  instruments  and 
ligatures,    and    another    the 

sponges.  Preparations  must  also  be  made  for  the  resuscitation  of  the  child  if 
necessary,  and  a  person  versed  in  such  methods  should  stand  ready  to  receive 
and  care  for  the  child. 

Position  of  the  Fetus. — The  position  of  the  fetus  should  previously  be  made 
out  as  accurately  as  possible,  as  with  this  fact  before  us  it  is  often  easier  to 
extract  the  fetus. 

Abdominal  Incision. — The  incision  is  made  in  the  median  line,  five  or  six 
inches  (12.7  to  15.24  cm.)  long,  usually  with  the  umbilicus  as  its  middle  point. 
When  the  fundus  stands  very  high  in  the  abdomen,  as  it  usually  does  in  abso- 
lute pelvic  contraction,  the  bulk  of  the  incision  is  best  made  above  the  umbili- 
cus, thus  securing  a  high  opening  in  the  uterus.  Very  little  bleeding  occurs 
from  the  thin  abdominal  walls,  and  clamps  should  control  any  that  takes  place. 
After  the  abdomen  is  opened  there  are  some  variations  in  the  technique.      It 


Fig.  1237. — ^^CoNTROL  of  the  Hemorrhage  in  CjES.\- 
REAN  Section  by  the  Hands  of  an  Assistant 
Grasping  Each  Broad  Ligament. 


1014  OBSTETRIC  SURGERY. 

is  advisable  to  be  sure  that  the  uterus  is  not  greatly  rotated  on  its  long  axis,  and 
this  fact  can  be  ascertained  by  noting  the  position  of  the  Fallopian  tubes.  The 
next  step  is  the  opening  of  the  uterus,  before  which  two  important  matters  are  to 
be  attended  to.  These  are  the  protection  of  the  abdominal  cavity  and  measures 
for  the  control  of  hemorrhage. 

Protection  of  the  Abdominal  Cavity  and  Control  of  Hemorrhage. — The  abdo- 
minal cavity  is  protected  by  the  use  of  properly  disposed  gauze  pads  around  the 
edges  of  the  widely  retracted  wound,  and  by  an  assistant  lifting  the  uterus 
firmly  against  the  edges  of  the  wound  (Fig.  1237).  The  hemorrhage  from  the 
uterine  incision  was  formerly  controlled  by  a  strong  elastic  ligature  drawn 
right  over  the  fundus  and  slipped  down  as  low  as  possible  and  tightened,  or, 
better,  by  the  hands  of  an  assistant,  one  grasping  each  broad  ligament  and  by 
judicious  pressure  obtaining  the  same  result,  and  at  the  same  time  steadying  the 
uterus  (Fig.  1237).  These  are  unnecessary  if  the  operation  is  quickly  per- 
formed and  are  even  dangerous  by  predisposing  to  subsequent  uterine  atony 
and  hemorrhage. 

Uterine  Incision. — Two  methods  of  procedure  are  now  before  the  operator, 
namely,  to  open  the  uterus  in  situ,  without  delivering  the  organ  through  the  ab- 
dominal wound,  and  the  other  to  lift  the  uterus  out  of  the  abdomen  before 
opening  it. 

The  former  plan  should  be  pursued  in  all  cases  in  which  no  infection  is  pres- 
ent, and  the  latter  when  by  reason  of  previous  repeated  attempts  at  delivery  we 
have  reason  to  suspect  infection  of  the  uterus.  [*  J-. 

X.  The  abdominal  cavity  being  protected  by  gauze  pads,  and  by  an  assistant 
holding  the  uterus  close  up  to  the  abdominal  wound  (Fig.  1237),  the  incision  into 
the  uterus  should  be  made  rapidly  down  to  the  membranes,  and  should  be  about 
six  inches  (15.24  cm.)  long.  If  the  placenta  is  met,  it  is  separated  and  pushed 
aside,  or  even  bored  through  with  the  fingers,  but  not  cut. 

2.  Should  we  have  reason  to  suspect  that  the  uterus  is  infected,  then  before 
making  the  uterine  incision,  the  organ  should  be  lifted  out  through  the  abdomi- 
nal incision,  and  not  opened  until  we  have  thoroughly  protected  the  abdominal 
cavity  from  infection  from  the  uterine  contents  by  placing  around  and  behind 
the  uterus  sterile  towels. 

The  proposition  of  Fritsch  (1897)  to  open  the  uterus  by  a  transverse  incision 
over  the  fundus,  in  order  to  cut  parallel  to  the  course  of  the  ovarian  blood-vessels, 
and  thus  to  avoid  hemorrhage,  has  had  many  indorsers,  but  the  method  has  no 
special  advantage  over  the  classic  longitudinal  incision. 

Rupture  of  Membranes  and  Delivery  of  Fetus. — As  soon  as  the  incision  is  com- 
pleted the  left  hand  of  the  operator  is  introduced  and,  without  rupturing  the 
membranes  if  possible,  the  head  is  sought.  The  time  has  now  come  for  the  rup- 
ture of  the  membranes  and  the  seizure  of  the  head  or  feet,  after  which  the  de- 
livery should  be  completed  as  rapidly  as  possible.  The  hand  in  the  uterus  should 
not  be  withdrawn  until  the  complete  extraction  of  the  child  is  assured,  since  the 
uterus  contracts  very  quickly  after  the  m.embranes  have  been  opened.  Extrac- 
tion should  be  done  very  deliberately.  The  fetal  head  is  sometimes  firmly 
grasped  by  the  lower  uterine  segment,  and  to  liberate  it  a  finger  of  one  hand 
should  be  hooked  into  the  mouth  and  the  head  flexed  until  the  smallest  diameters 
are  opposed  to  the  superior  strait  and  lower  uterine  segment.  With  the  other 
hand  the  operator  makes  traction  upon  the  feet  in  the  axis  of  the  uterus.  If  the 
head  does  not  follow,  the  second  hand  placed  astride  the  neck  makes  pressure 
upon  the  shoulders,  and  at  the  same  time  endeavors  to  maintain  the  head  in  flexion. 
(See  Smellie-Veit  method,  page  978.)      An  extreme  condition  of  incarceration 


CESAREAN  SECTION. 


1015 


of  the  head  in  the  superior  strait  should,  of  course,  be  recognized  and  corrected 
before  the  operation.  After  the  child  is  extracted  it  is  handed  to  an  assistant 
to  be  wrapped  in  warm  sterilized  gauze,  while  the  cord  is  clamped  in  two 
places,  between  which  it  is  divided,  a  ligature  being  applied  to  the  stump  sub- 
sequently. 

Placental  Delivery. — To  detach  the  placenta  it  should  be  grasped  and  squeezed 
like  a  sponge,  whereupon  it  gradually  comes  away.  Under  gentle  traction  the 
membranes  also  peel  off.  In  some  cases  the  placenta  lies  loose  in  the  uterus  after 
the  fetus  is  taken  out.  Care  is  necessary  at  this  stage  to  keep  the  fluids  from  en- 
tering the  general  abdominal  cavity.  Many  operators  raise  the  uterus  entirely 
out  of  the  abdominal  cavity  and  hold  it  in  position  for  suturing  by  slipping  a  hot 
sterilized  towel  under  it. 

Uterine  Sutures. — Sutures  should  be  applied  in  three  planes.  Those  of  the 
deepest  row  should  be  about  one-half  inch  (1.27  cm.)  apart,  they  should  be  intro- 
duced into  the  external  aspect  of  the  uterus  about  one-fifth  of  an  inch  (0.53  cm.) 
from  the  margin  of  the  incision  and  should  emerge  at  the  level  of  the  space  be- 


FiG.  1238. — Suture  op  the  Uterine  Wall  Extending      Fig.    1239. — Suture    of   the 
TO  but  not  through  the  Decidua.  Peritoneum   in  Cesarean 

Section. 


tween  the  mucous  and  muscular  layers  (Fig.  1238).  They  are  then  carried  across 
the  wound  to  the  same  stratum  of  the  opposite  cut  edge  and  outward  through  the 
uterine  wall.  The  second  plane  consists  of  half-deep  sutures,  inserted  between 
the  deep  sutures  for  closer  approximation.  Finally,  the  superficial  sutures 
of  fine  silk  unite  accurately  the  peritoneal  coat  of  the  uterus  (Fig.  1239).  It 
must  be  borne  in  mind,  however,  that  the  first  or  deep  layer  is  capable  of  some- 
thing more  than  mere  coaptation  and  constitutes  a  distinct  form  of  hemostasis. 
If  the  usual  measures  for  checking  hemorrhage  have  been  inadequate,  the  deep 
sutures  may  be  inserted  and  tied  at  once.  The  presence  of  a  slight  anemic  layer 
about  the  tightened  suture  shows  us  that  the  purpose  of  the  latter  is  served ;  to 
go  further  would  be  to  cut  off  some  of  the  necessary  blood-supply  and  favor  septic 
infection.  There  is  no  need  of  putting  any  antiseptic  material  in  the  uterine 
cavity,  nor  does  it  need  any  other  drainage  than  what  takes  place  naturally 
through  the  os,  provided  the  latter  has  been  previously  dilated. 

Ligation  of  the  Fallopian  Tubes. — With  the  consent  of  the  patient,  the  next 
step  in  the  operation  is  the  ligation  and  division  of  the  Fallopian  tubes. 


1016  OBSTETRIC  SURGERY. 

Omental  Adhesions. — The  next  step  has  reference  to  the  prevention  of  omental 
adhesions.  The  omentum,  which  is  normally  situated  in  front  of  the  uterus,  is 
brought  down  and  carried  behind  that  organ  in  order  to  avoid  the  formation  of 
utero-omental  adhesions. 

Abdominal  Sutures. — The  abdominal  wound  is  closed  with  four  planes  of 
sutures:  viz.,  continuous  catgut  suture  for  the  peritoneum,  interrupted  catgut 
sutures  for  the  muscles  and  fascia,  and  silkworm-gut  for  the  skin. 

Hemorrhage. — The  operation  of  laparo-hysterotomy  thus  performed  is  not 
attended,  as  a  rule,  by  much  hemorrhage.  If  the  bleeding  is  more  profuse  than 
usual,  it  may  be  controlled  by  tightening  the  elastic  ligature  or  by  the  hands  of 
an  assistant  grasping  the  broad  ligaments  and  their  contained  blood-vessels.  It 
is  not  well  to  constrict  the  ligature  too  persistently,  or  to  tie  more  than  one  turn, 
for  fear  of  provoking  a  reactionary  hemorrhage  when  the  constriction  is  with- 
drawn. It  is  better  to  control  the  hemorrhage  by  the  measures  customary  in 
natural  delivery;  viz.,  friction,  heat  (application  of  hot  cloths  in  this  case),  and 
the  hypodermic  injection  of  ergot.  The  latter  drug  may  also  be  administered 
as  a  prophylactic  at  the  moment  the  fetus  is  removed.  In  parenchymatous 
bleeding  sponging  with  hot  gauze  is  advisable.  The  suturing  of  the  uterine  in- 
cision has  naturally  a. hemostatic  effect. 

Bladder.  Bowels.  Nursing. — The  bladder  should  be  emptied  by  catheter,  at 
the  end  of  the  operation  and  as  often  thereafter  as  necessary.  After  each  evacua- 
tion a  thorough  vulval  douche  should  be  administered  (see  page  88i).  A  hypo- 
dermic of  morphin  is  usually  indicated  during  the  first  post-operative  day,  but 
at  the  expiration  of  twenty-four  hours  the  child  should  be  allowed  to  nurse  and 
the  drug  should  be  discontinued.  On  the  third  post-operative  day  the  bowels 
should  be  moved  by  enema. 

After-treatment. — The  abdominal  sutures  should  be  removed  from  the  eighth 
to  the  twelfth  day.  An  examination  should  be  made  after  cicatrization  is  complete 
to  determine  whether  or  not  adhesions  have  formed  with  resulting  fixation  of  the 
uterus.  As  matters  of  interest  and  record  it  is  valuable  that  the  operator,  after 
emptying  the  uterus,  should  note  the  position  of  the  contraction  ring  and  measure 
the  true  conjugate.  The  after-treatment  is  practically  the  same  as  after  an  ex- 
tensive laparotomy  for  any  condition. 


XIII.  ABDOMINAL  HYSTERECTOMY. 

This  operation  is  performed  through  the  abdominal  incision,  and  consists 
either  in  the  amputation  of  the  uterus  at  the  junction  of  the  body  and  the  cer- 
vix, and  is  then  termed  Incomplete  Abdominal  Hysterectomy,  or,  secondly,  in 
the  extirpation  of  the  entire  uterus,  including  the  cervix,  and  is  then  known  as 
Complete  Abdominal  Hysterectomy  or  Panhysterectomy. 

Indications. — Hysterectomy  proper  has  almost  entirely  superseded  the  Porro 
operation  in  instances  where  it  is  considered  best  to  remove  the  uterus  after 
Caesarean  section  or  rupture  of  the  uterus.  Its  principal  application  is  in  cases 
in  which  in  Caesarean  section  sepsis  of  the  uterus  is  suspected  or  known  to  be 
present;  and  in  cancerous  or  myomatous  growths  of  the  uterus.  In  the  excep- 
tional cases  of  uterine  atony  following  Caesarean  section  abdominal  hysterectomy 
may  be  the  only  means  to  control  the  resulting  persistent  hemorrhage. 

Operation. — The  operation  is  practically  the  same  as  in  the  non-pregnant 
state,  and  for  its  minute  technique  the  student  is  referred  to  works  on  gynec- 
ology. 


ABDOMINAL  HYSTERECTOMY. 


1017 


The  position  of  the  patient  is  the  dorsal  one  with  provision  for  raising  the 
pelvis  into  the  Trendlenburg  posture  when  required.  The  assistants  are  an 
anesthetizer,  two  assistants,  and  a  general  nurse.  The  instruments  required  are, 
scalpel,  blunt-pointed  scissors,  6  artery  clamps,  2  abdominal  retractors,  heavy 
hysterectomy  traction  forceps,  4  long-bladed  broad  ligament  clamps,  dressing 
forceps,  right  and  left  pedicle  needles,  needle- holder,  6  full-curved  needles,  3 
straight  needles.  No.  12  braided  silk  or  No.  2  or  3  chromic  catgut.  No.  i  and  2 
plain  catgut,  silkworm-gut.  Because  of  the  laxness  of  the  abdominal  walls, 
pelvic  floor,  and  uterine  ligaments,  and  the  prominence  of  the  uterine  vessels, 
the  operation  is  more  readily  performed  in  the  puerperal  than  in  the  non-puer- 
peral state.  By  reason  of  this  laxness,  the  entire  uterus  and  upper  portion  of 
the  cervix  can  by  traction  be  safely  brought  through  the  abdominal  incision  and 


Fig.  1240. — Incomplete  Abdominal  Hys- 
terectomy. Shows  the  uterus  drawn 
through  the  abdominal  incision  with  the 
broad  ligament  clamps  applied;  ovarian 
vessels  and  round  ligaments  ligated  sep- 
arately, and  broad  ligaments  divided. 


Fig.  1 241. — Incomplete  Abdominal  Hys- 
terectomy. Shows  the  uterus  drawn  to 
one  side  and  the  opposite  uterine  vessels 
being  ligfated. 


the  clamps  and  ligatures  applied  upon  the  surface  of  the  abdomen  instead  of  in 
the  pelvic  cavity.  Except  in  septic  and  cancerous  conditions  the  incomplete 
operation  will  usually  suffice,  and  is  the  one  more  quickly  and  safely  performed. 

Incomplete  Hysterectomy. — Figs.  1240  to  1245  show  the  steps  in  incomplete 
hysterectomy,  and  it  will  be  noted  from  the  illustrations  that  the  entire  uterus  is 
delivered  through  the  incision.  Also  that  the  broad  ligaments  are  clamped,  and 
the  ovarian  and  uterine  vessels  and  round  ligaments  ligated,  the  broad  ligament 
divided,  the  bladder  stripped  down  and  the  uterus  amputated  at  the  level  of  the 
utero-cervical  junction,  upon  the  surface  of  the  abdomen.  The  uniting  of  the 
stumps  of  the  ovarian  and  uterine  vessels,  and  closing-in  of  the  raw  surfaces  by 
uniting  the  anterior  and  posterior  flaps  of  the  peritoneum,  of  necessity  is  per- 
formed within  the  abdomen  (Figs.  1244  and  1245). 

Complete  Hysterectomy. — Figs.  1 246  to  1 250  show  the  steps  in  complete  hyster- 


1018 


OBSTETRIC  SURGERY 


Fig.  1242. — Incomplete  Abdominal  Hys- 
terectomy. The  broad  ligaments  are 
clamped  close  to  the  uterus.  The  uterine 
and  ovarian  vessels  and  round  ligaments 
ligated  and  incised.  The  incision  above 
the  utero-vesical  reflection  of  the  perito- 
neum has  been  made  and  the  bladder  is 
being  stripped  down  from  the  uterus  with 
the  finger. 


Fig. "^1243. — Incomplete  Abdominal  Hys- 
terectomy. The  bladder  has  been 
stripped  down  and  the  uterus  is  drawn 
upward  and  to  one  side  and  is  being  ampu- 
tated at  the  utero-cervical  junction. 


Fig.  1244. — Incomplete  Abdominal  Hys- 
terectomy. On  the  right  side  the  stumps 
of  the  ovarian  and  uterine  vessels  are  trans- 
fixed by  a  single  ligature  of  No.  2  plain  cat- 
gut. On  the  left  side  this  ligature  is  drawn 
tight  and  tied,  thus  uniting  the  two  stumps 
over  the  pedicle  of  the  round  ligament, 
and  drawing  the  broad  ligament  tense  to 
assist  in  the  support  of  the  vault  of  the 
vaofina. 


Fig.  1245. — Incomplete  Abdominal  Hys- 
terectomy. The  stumps  of  the  ovarian 
and  uterine  vessels  and  the  round  liga- 
ment are  pushed  under  the  peritoneiun 
and  the  anterior  and  posterior  flaps  of  the 
peritoneum  are  brought  together  by  a 
continuous  suture  of  No.  i  plain  catgut. 


ABDOMINAL  HYSTERECTOMY. 


1019 


Fig.  1246. — Total  Abdominal  Hysterec- 
tomy. The  broad  ligaments  are  clamped 
close  to  the  uterus.  The  uterine  and  ovar- 
ian vessels  and  round  ligaments  ligated  and 
incised.  The  incision  above  the  utero- 
vesical  reflection  of  the  peritoneum  has 
been  made  and  the  bladder  is  being  strip- 
ped down  from  the  uterus  with  the  finger. 


Fig.  1247. — Total  Abdominal  Hysterec- 
tomy. The  uterus  is  drawn  upward  with 
the  traction  forceps  so  as  to  put  the  vag- 
inal junction  on  the  stretch.  The  bladder 
is  pushed  forward  with  the  index  finger  of 
one  hand  and  with  a  scalpel  in  the  other 
hand  the  anterior  vaginal  cul-de-sac  is  in- 
cised. 


Fig.  1248. — Total  Abdominal  Hysterec- 
tomy. The  index  finger  of  the  left  hand  is 
passed  through  the  incision  into  the  vagina, 
and  with  a  pair  of  scissors  in  the  right  hand 
the  incision  is  carried  entirely  around  the 
cervix,  separating  the  latter  from  its  vag- 
inal attachments. 


Fig.  1249. — Total  Abdominal  Hysterec- 
tomy. The  opening  in  the  vagina  is  closed 
with  No.  I  plain  catgut,  after  all  bleeding 
points  have  been  Hgated  and  the  stumps 
of  the  ovarian  and  uterine  vessels,  and  the 
anterior  and  posterior  flaps  of  the  peri- 
toneum treated  as  in  Fig.  1244. 


1020 


OBSTETRIC  SURGERY. 


ectomy,  and  I  have  purposely  indicated  in  my  drawings  that  the  uterus  is  not 
drawn  up  as  high  through  the  abdominal  incision  as  in  the  incomplete  operation, 
though  it  could  safely  be  drawn  up  much  higher.  The  clamping  of  the  broad 
ligament,  the  ligation  of  the  ovarian  and  uterine  vessels  and  round  ligament, 
the  dividing  of  the  broad  ligament,  and  the  stripping  down  of  the  bladder  are 
the  same  as  in  the  incomplete  operation  (Figs.  1240,  1242).     The  vagina  is  then 


Fig.  1250. — Total  Abdominal  Hysterectomy.     Shows  the  anterior  and  posterior  flaps  of 
the  peritoneum  brought  together  as  in  Fig.  1245. 

Opened  into  as  in  Fig.  1247,  and  the  incision  carried  around  the  cervix,  separating 
the  latter  from  its  vaginal  attachments  as  in  Fig.  1247.  The  opening  in  the 
vagina  is  now  closed  by  a  continuous  suture  of  No.  i  plain  catgut,  and  the 
stumps  of  the  ovarian  and  uterine  vessels  united  (Fig.  1249).  The  anterior  and 
posterior  flaps  of  peritoneum  are  now  made  to  cover  the  raw  surfaces  by  a  con- 
tinuous suture  of  plain  catgut  (Fig.  1250). 


XIV.  PORRO-C/ESAREAN    SECTION. 

This  operation  is  essentially  a  supravaginal  amputation  of  the  uterus,  and 
under  the  name  of  Porro  operation  or  Porro-Caesarean  section  it  has  long  been 
domiciled  in  Italy. 

Indications. — The  original  indication  for  the  Porro  amputation  was  the  pre- 
vention of  sepsis,  when  the  uterine  cavity  gave  evidences  of  infection,  and  to 
escape  the  dangers  of  hemorrhage  and  leakage  from  the  uterine  incision  of  the 
ordinary  Cesarean  section. 

An  additional  indication  was  the  prevention  of  further  pregnancies  in  those 
illegitimately  pregnant  in  the  destitute,  and  in  cases  of  tubercular  and  cardiac 
disease. 

This  last  indication  is  to-day  really  secured  in  Csesarean  section  by  excising 
the  tubes,  removing  the  ovaries,  or  by  an  incomplete  or  total  hysterectomy. 

At  the  present  day  the  Porro  operation  is  rarely  performed,  because  it  is  not 
in  keeping  with  advanced  surgical  principles,  because  of  the  prolonged  slough- 
ing and  healing  of  the  extra-peritoneal  stump,  and  the  inverted  scar  which  re- 
sults in  the  anterior  abdominal  wall. 

I  am  describing  and  illustrating  it  here  because  I  believe  it  is  still  a  life-sav- 
ing measure  in  cases  of  serious  uterine  rupture,  and  labor  obstructed  by  a  large 
fibroid  tumor  in  the  hands  of  those  who  question  their  ability  to  perform  the 
undoubtedly  more  correct  surgical  procedure  of  modem  hysterectomy;  and  also 
when  haste  is  of  vital  importance,  as  in  rupture  of  the  uterus,  when  the  condi- 


PORRO-CMSAREAN  SECTION. 


1021 


Pig.  1251. — PoRRO-C^SAREAN  Section. 
Clamps  are  applied  to  the  broad  ligaments 
and  the  latter  ligated,  and  cut  through. 
Elastic  ligature  is  applied  and  tied  tightly 
above  the  cervix.  Two  transfixion  pins 
are  passed  above  the  ligature. 


Fig.  1252. — PoRRO-C^SAREAN  Section 
The  uterus  is  amputated  a  short  distance 
above  the  transfixion  pins. 


Fig.  1253. — PoRRO-CiESAREAN  Section. 
Shows  the  peritoneum  closed  with  plain 
catgut  and  the  stitches  for  the  abdominal 
wall  tied  below  and  in  place  above. 


Fig.  1254. — PoRRO-C.-ESAREAN  Section. 
Shows  the  abdominal  wall  closed,  and  the 
stump  of  the  uterus  being  closed  with  a 
continuous  suture. 


1022  OBSTETRIC  SURGERY. 

tion  of  the  woman  is  such  that  the  shock  of  operation  must  be  reduced  to  a 
minimum. 

Operation. — The  preparation  and  position  of  the  patient  are  the  same  as  for 
Cassarean  section  proper. 

Instruments. — Knife,  stout  straight  scissors,  six  artery  clamps,  No.  2  plain 
catgut,  3  medium  curved  needles  threaded  with  No.  2  catgut,  six  2^-inch 
straight  needles  threaded  with  silkworm-gut,  needle-holder,  a  stout  rubber  liga- 
ture and  two  transfixing  pins  for  the  stump  (Fig.  1252),  adhesive  plaster,  dress- 
ings. 

Step  One. — The  abdominal  incision  is  made  as  in  Caesarean  section,  hemor- 
rhage is  controlled,  the  uterus  is  turned  out  of  the  abdomen,  and  the  abdomi- 
nal cavity  protected  from  contamination  as  in  cases  of  Caesarean  section  where 
a  septic  process  in  the  uterus  is  suspected.  The  uterine  incision  is  now  made 
as  in  Caesarean  section  and  the  child  delivered.  The  cord  and  placenta  are  best 
left  in  the  uterus. 

Step  Two. — The  uterus  is  held  well  up  in  the  abdominal  incision  by  heavy 
forceps  grasping  the  fundus  (Fig.  12 51)  and  a  stout  rubber  ligature  is  firmly 
knotted  about  the  junction  of  the  uterus  with  the  cervix,  care  being  taken  not 
to  include  the  bladder,  ureters  or  intestine  (Fig.  1251). 

Step  Three. — The  infundibulo-pelvic  ligaments  are  now  ligated  with  No.  3 
plain  catgut  near  the  pelvic  brim,  and  cut  through  on  the  uterine  side  (Fig. 
1251). 

Step  Four. — Transfixion  pins  are  passed  through  the  stump  at  right  angles 
just  above  the  rubber  ligature  and  the  uterus  amputated  a  short  distance  above 
(Fig.  1252).  The  transfixion  pins  rest  upon  the  abdominal  wall  and  prevent  re- 
cession of  the  stump,  and  care  must  be  taken  that  they  do  not  include  the 
bladder  or  ureters. 

Step  Five. — The  stump  is  steadied  in  the  lower  angle  of  the  abdominal  in- 
cision and  through-and-through  interrupted  silkworm-gut  sutures  are  introduced 
to  close  the  abdomen,  the  lowest  of  which  transfixes  the  stump  (Fig.~  1253). 

Step  Sixth. — The  peritoneum  is  closed  by  a  continuous  suture  of  No.  2  plain 
catgut,  the  lower  portion  being  stitched  to  the  serous  surface  of  the  pedicle  be- 
low the  transfixion  pins,  and  the  abdomen  closed  in  the  usual  manner  (Fig. 

1254)- 

Step  Seven. — The  peritoneum  of  the  pedicle  is  drawn  over  the  stump  by  a 
continuous  suture  of  No.  2  plain  catgut. 

Step  Eighth. — The  stump  is  dressed  with  dry  dressings.  After  about  two 
weeks  the  stump  with  pins  and  rubber  ligature  sloughs  away,  leaving  a  concave 
wound  which  heals  by  granulation. 


XV.  VAGINAL  C/ESAREAN  SECTION. 

Definition. — A  deep  incision  of  the  anterior  cervical  wall  extending  beyond 
the  internal  os  into  the  lower  uterine  segment,  and  the  deliver}^  of  the  fetus 
through  this  opening  by  the  forceps  or  version. 

To  Accononci  in  1896,  and  to  Diihrrsen  in  the  same  year,  belong  the  credit 
for  the  introduction  of  vaginal  Caesarean  section. 

Indications. — Although  more  than  one  hundred  cases  are  now  on  record  this 
operation  is  still  in  its  experimental  stage,  because  we  have  yet  to  learn  of  the 
danger  of  extension  of  the  incision  into  the  lower  uterine  segment  in  the  extrac- 


VAGIlSfAL  CESAREAN  SECTION. 


1023 


-^ 


Fig.  1255. — Vaginal  Cesarean  Section. 
Shows  initial  incision.  Transverse  incis- 
ion one  and  a  half  inches  through  mucous 
membrane  at  utero- vaginal  junction  and 
vertical  incision  extending  from  the 
middle  point  of  the  transverse  incision 
longitudinally  downward  through  mucous 
membrane  of  anterior  vaginal  wall  to  a 
point  immediately  below  the  urethra,  thus 
making  a  "T"  incision. 


Fig.  1256. — Vaginal  Cesarean  Section. 
The  flaps  of  the  incision  are  turned  back 
with  the  finger  or  blunt  dissector  and 
the  bladder  is  strippd  away  from  the 
cervix. 


y 


.,-^r^. 


Fig,  1257. — Vaginal  Cesarean  Section. 
The  anterior  wall  of  cervix  and  lower  uter- 
ine segment  are  bisected  in  the  median 
line  up  to  the  reflection  of  the  bladder,  ex- 
posing the  amniotic  bag. 


Fig.  125S. — Vaginal  C.^sarean  Section. 
The  incisions  in  the  cervix  and  lower  uter- 
ine segment  are  closed  with  catgut  after 
emptying  of  the  uterus,  and  the  vaginal 
incisions  are  brought  together  over  these 
with  catgut. 


1024  OBSTETRIC  SURGERY. 

tion  of  the  fetus,  and  injury  to  the  bladder  resulting  from  the  operation.  It  is 
probable,  moreover,  that  the  scar  of  the  vaginal  Caesarean  section  in  the  thinned- 
out  lower  uterine  segment  in  subsequent  pregnancies  will  more  readily  rupture 
than  that  of  the  Csesarean  section  by  the  abdominal  route,  which  latter  is  near 
the  fundus.  In  many  of  the  cases  reported  and  in  most  of  those  that  have 
come  under  my  personal  observation,  delivery  by  the  abdominal  route,  or  even 
by  combined  instrumental  and  manual  dilatation  of  the  cervix,  would,  it  ap- 
pears to  me,  have  been  preferable  to  the  vaginal  Caesarean  section. 

The  chief  indication  of  the  operation  is  in  eclampsia,  where  rapid  delivery 
is  indicated  and  the  condition  of  the  cervix  renders  artificial  rapid  dilatation 
dangerous  or  impossible.  Maternal  cardiac  disease  and  stenosis  of  the  cervix, 
and  possibly  cancer  of  the  cervix,  are  other  indications.  A  markedly  contracted 
pelvis  with  a  true  conjugate  of  3.1  inches  (8  cm.)  is  always  a  contraindication 
to  the  vaginal  operation.  Theoretically  placenta  praivia  with  a  long  undilated 
cervix  would  appear  to  be  an  indication. 

Operation. — The  patient  is  placed  in  the  ordinary  lithotomy  position,  and 
prepared  as  for  a  vaginal  hysterectomy.  The  assistants  required  are,  an  anes- 
thetizer,  two  assistants,  and  an  obstetric  nurse.  The  following  instruments 
should  be  in  readiness :  one  perineal  and  three  long  vaginal  retractors ;  4  bullet 
forceps;  strong  straight  scissors;  scalpel;  artery  clamps;  needle-holder;  6  full- 
curved  needles;  No.  i  and  2  plain  and  No.  3  chromic  catgut;  vaginal  dressings. 

First  Step. — The  perineum  is  depressed  with  a  broad  speculum,  and  the 
cervix  is  grasped  with  two  bullet  forceps,  placed  one  on  each  side  of  the  median 
line  about  half  an  inch  (1.25  cm.)  apart.  The  cervix  is  now  drawn  downward  and 
backward  into  the  vulval  outlet,  and  the  mucous  membrane  at  the  utero- vaginal 
junction  is  incised  laterally  to  the  extent  of  an  inch  and  a  half  (3.81  cm.).  In 
order  to  secure  a  larger  field  to  work  in,  some  add  a  second  incision  at  right 
angles  to  the  above,  and  extending  from  the  middle  point  of  the  transverse 
incision  longitudinally  downward  through  the  mucous  membrane  of  the  anterior 
vaginal  wall,  thus  making  a  "T"  incision  (Fig.  1255). 

Second  Step. — The  bladder  is  now  stripped  away  by  the  finger  and  blunt 
dissection  up  to  the  point  of  deflection  of  the  peritoneum  (Fig.  1256). 

Third  Step. —  A  long  narrow-bladed  speculum  is  now  inserted,  which  ele- 
vates the  peritoneum  and  exposes  to  view  the  length  of  the  cervix  and  portion 
of  the  lower  uterine  segment  (Fig.  1257). 

Fourth  Step. — With  a  pair  of  strong,  straight,  blunt-pointed  scissors  the 
cervix  is  now  incised  anteriorly  in  the  median  line  through  the  internal  os. 
Little  bleeding  usually  results  (Fig.  1257). 

FijtJi  Step. — The  incision  in  the  uterus  is  now  stretched  either  with  the  two 
index- fingers  (Fig.  1257)  or  with  one  hand  inserted  into  the  vagina  after  the  re- 
moval of  all  instruments.      The  fetal  membranes  now  prolapse  into  the  wound. 

Sixth  Step. — The  fetus  is  now  delivered  by  forceps  or  version,  preferably 
the  latter,  the  placenta  and  membranes  manually  extracted,  and  the  uterine 
cavity  washed  out  with  normal  saline  solution  and  packed  with  iodoform  gauze. 
It  will  sometimes  be  necessary  to  extend  the  uterine  incision  in  order  to  extract 
the  fetal  head. 

Seventh  Step. — The  perineal  retractor  is  again  placed  in  position,  each  side 
of  the  incised  cervix  again  caught  with  bullet  forceps,  and  the  long  narrow  re- 
tractor placed  to  hold  up  the  bladder  and  peritoneum  anteriorly  (Fig.  1257). 
The  incision  in  the  cervix  is  now  closed  with  interrupted  suture  of  No.  3  twenty- 
day  chromic  catgut,  and  the  vaginal  incisions  with   No.   2  plain  catgut  (Fig. 


DELIVERY  OF' THE  PLACENTA   AND   MEMBRANES.         1025 

1258).     The  external  portion  of  the  cervical  wound  should  be  left  in  order  to 
prevent  undue  contraction  and  improper  uterine  drainage. 

It  is  technically  permissible  to  divide  the  pelvic  floor  (Fig.  11 00)  and  perito- 
neum (episiotomy),  should  the  extraction  of  the  fetus  be  otherwise  impossible. 


XVI.   CESAREAN  SECTION  ON  THE  DEAD  AND  DYING. 

Cassarean  section  on  the  dead  has  fallen  into  disrepute  at  various  times  and  in 
different  localities  for  one  of  three  reasons:  First,  statistics  covering  a  limited 
experience  have  appeared  to  demonstrate  that  but  few  children  were  delivered 
alive  in  this  manner,  and  that  these  few  succumbed  to  secondary  mortality; 
second,  cataleptic  women  have  been  subjected  to  laparotomy  under  these  circum- 
stances; third,  dead  and  dying  women  can  be  delivered  by  version  or  forceps 
without  mutilation,  and  the  children  thus  delivered  show  a  high  percentage  of 
survivals.  Nevertheless  the  spirit  of  the  old  lex  regia  which  ordained  that  a  dead 
woman  in  advanced  pregnancy  should  be  delivered  by  celiotomy  is  still  in  force, 
because  it  can  be  carried  out  with  greater  rapidity  than  version  and  extraction 
and  forceps  delivery.  We  know  that  the  fetus  may  survive  its  dead  mother  for 
a  certain  period  (see  Coffin  Birth,  page  669),  and  that  prompt  intervention  may 
save  life.  Naturally  the  child  thus  delivered  will  be  profoundly  asphyxiated 
from  failure  of  the  maternal  circulation,  but  it  may  be  resuscitated.  When  the 
mother  has  succumbed  to  a  severe  type  of  disease,  the  child  is  usually  profoundly 
affected  even  before  her  death.  The  chances  of  survival  are  therefore  far  more 
unfavorable  than  in  cases  of  sudden  death  of  healthy  mothers,  under  which 
circumstances  children  have  survived  in  utero  for  as  long  a  period  as  half  an  hour. 
But  even  when  the  mother  is  dying  by  inches  of  some  severe  general  disease, 
the  fetus  still  has  a  prospect  of  survival  if  celiotomy  is  performed  before  the 
entire  failure  of  the  placental  circulation.  It  is  possible  also  to  extract  the  child 
rapidly  per  vaginam  from  its  moribund  mother.  This  operation  is,  of  course,  a 
most  delicate  one,  and  could  be  put  in  practice  only  under  certain  conditions, 
such  as  consent  of  the  mother  and  her  relatives  in  advance  and  after  consulta- 
tion with  representative  medical  colleagues.  The  patient  should  be  subjected 
to  the  most  valid  differential  tests  of  death  or  the  moribund  state.  In  operating 
upon  the  dead  or  dying  the  same  general  technique  obtains  as  in  the  ordinary 
conservative  operation  on  the  living.  One  cannot,  however,  always  be  par- 
ticular in  the  choice  of  an  instrument  for  making  the  incisions. 


XVII.   DELIVERY  OF  THE  PLACENTA  AND  MEMBRANES. 

I.   Credfs    Adethod.     2.   Dublin    Method,     j.   Digital    Extraction.     4.  Instrumental    Extrac- 
tion.    5.  Manual  Extraction.     6.   Digital  Curettage.     7.   Instrumental  Curettage. 

I.  Crede's  Method  of  Placental  Expression. — According  to  Credo's  original 
account  of  his  method,*  "  the  simplest  and  most  natural  method  of  artificially 
removing  the  placenta  consists  in  inciting  and  invigorating  the  sluggish  activity 
of  uterine  contraction.  A  single  energetic  contraction  of  the  uterus  brings  the 
entire  process  to  a  rapid  end.  I  have  succeeded  in  innumerable  cases,  and  with- 
out exception,  in  producing  an  artificial  and  powerful  contraction  of  the  uterus 

♦"Klinische  Vortrage  uber  Geburtshulfe,"  1853,  p.  599. 
65 


1026 


OBSTETRIC  SURGERY. 


in  from  fifteen  to  thirty  minutes  after  the  birth  of  the  child,  and  when  the  uterine 
action  was  ever  so  sluggish,  by  rubbing  the  fundus  and  corpus  uteri  through  the 


Fig.   1259. — Crede's  Method  of  Placental  Expression. — {The  upper  figure  is  from  a 
photograph  taken  at  the  Emergency  Hospital.) 


abdominal  wall — gently  at  first  but  gradually  with  the  expenditure  of  more  force. 
As  soon  as  the  contraction  has  reached  its  maximum,  I  grasp  the  uterus  entire  in 


DELIVERY  OF  THE  PLACENTA   AND   MEMBRANES. 


1027 


such  a  way  that  the  fundus  lies  in  my  palm  while  the  fingers  and  thumb  make 
gentle  pressure  upon  the  body  of  the  organ.  I  invariably  feel  the  placenta  slipping 
from  beneath  my  fingers,  as  a  rule  with  such  violence  that  it  appears  at  the  ex- 
ternal genitals,  or  at  least  reaches  the  lowest  part  of  the  vagina.  The  patient 
experiences  no  discomfort  from  this  manipulation  beyond  an  increased  sensation 
of  pain  during  the  uterine  contractions,  and  it  becomes  unnecessary  to  introduce 
the  hand  into  the  birth  canal,  which  has  already  become  extremely  sensitive  as  a 


Pig.    1260. — DicjiTAL  Extractio.nt  of  the   Placenta   by  Traction  with  Two  Fingers 
Introduced  into  the  Cervix,  Assisted  by  Suprapubic  Pressure  upon  the  Fundus. 


result  of  the  expulsion  of  the  child.  The  uterus  remains  permanently  contracted, 
hemorrhage  is  therefore  less  to  be  feared,  and  an  inversion  of  the  uterus  can  never 
occur  as  a  result  of  a  regular  contraction,  although  this  accident  is  always  possible 
with  the  usually  adopted  method  of  removing  the  placenta."  Shortly  before  his 
death  Crede  modified  his  method  by  allowing  a  delay  of  thirty  minutes  after  ex- 
pulsion of  the  child  before  beginning  the  use  of  his  method. 

In  the  absence  of  a  positive  indication,  such  as  hemorrhage,  artificial  expul- 


1028 


OBSTETRIC  SURGERY. 


pRE:ssui?£- 


sion  of  the  placenta  should  not  be  resorted  to  until  post-partum  uterine  con- 
tractions have  failed,  after  at  least  half  an  hour,  to  cause  a  spontaneous  separa- 
tion of  the  placenta  and  membranes.  During  this  time  the  fundus  of  the  uterus 
should  be  held  in  the  hand  and  in  atonic  conditions  gently  rubbed,  but  never  in 
the  absence  of  a  positive  indication  vigorously  rubbed,  to  hasten  separation  of 
the  placenta  and  membranes,  nor  should  traction  ever  be  made  upon  the  cord  for 
the  same  purpose.  To  carry  out  the  method  properly  the  bladder  must  be  empty ; 
the  patient  is  placed  in  the  dorsal  position  with  the  knees  drawn  up  to  relax  the 
anterior  abdominal  wall  (Fig.  1259);  the  fundus  of  the  uterus  is  grasped  with  the 
whole  hand,  four  fingers  behind  and  the  thumb  in  front ;  during  a  uterine  contrac- 
tion the  fundus  is  compressed  between  the 
fingers  and  thumb,  the  fundus  being  at  the 
same  time  directed  as  far  backward  toward 
the  sacrum  as  circumstances  will  permit.  The 
other  free  hand  should  be  held  in  readiness  at 
the  vulva  to  prevent  a  too  precipitate  de- 
livery of  the  placenta,  as  otherwise  the  mem- 
branes may  be  torn  and  portions  retained. 

Should  expression  at  one  post-partum 
uterine  contraction  fail,  we  must  wait  for  the 
next  contraction  and  repeat  the  process.  In 
urgent  cases  both  hands  may  be  used  to  grasp 
the  fundus,  the  eight  fingers  behind  and  the 
two  thumbs  in  front.  In  this  case  particular 
care  must  be  taken  not  to  rupture  a  possible 
salpingitis  or  diseased  ovary. 

As  soon  as  the  placenta  emerges  from  the 
vulval  orifice  it  should  be  received  into  the 
hand  (Fig.  635).  If  the  membranes  do  not 
readily  come  away,  it  is  best  to  rely  upon  uter- 
ine compression  to  expel  them  rather  than  to 
twist  them  into  a  cord  by  turning  the  placenta 
over  and  over  gently,  and  so  gradually  separ- 
ating them.  Should  a  fragment  be  left  hang- 
ing from  the  cervix  or  vagina,  it  may  be  care- 
fully separated.  Such  bits  as  may  be  retained 
within  the  uterine  cavity  are  best  left  to  be 
discharged  in  the  lochia  if  there  is  no  hemor- 
rhage. After  the  expulsion  of  the  placenta  and 
membranes,  they  must  be  carefully  examined 
in  order  to  see  that  they  are  complete  (Fig. 

637). 
2.  Dublin  Method. — The  so-called  Dublin  method  of  extracting  the  placenta 
is  none  other  than  the  procedure  which  goes  by  Crede's  name.  It  is  true  that  the 
delivery  of  the  placenta  by  external  manipulation — as  opposed  to  traction  on  the 
cord — was  independently  originated  by  the  distinguished  Strasbourg  professor, 
and  was  popularized  throughout  the  world  through  his  personal  advocacy;  but 
it  is  none  the  less  true  that  this  method  of  extraction  has  been  carried  out  in 
Dublin,  almost  from  time  immemorial.  Hence  a  section  on  the  so-called  "  Dublin 
method  "  should  possess  chiefly  a  historical  interest.  This  question  of  priority 
was  first  agitated  by  M'Clintock  and  Barnes  in  1876.* 


Fig. 

OF 


1261.— Digital  Extraction 
A  Piece  of  Retained  Mem- 
branes BY  Two  Fingers  Intro- 
duced into  the  Vagina,  Assisted 
BY  Suprapubic  Pressure  upon 
THE  Fundus. 


*  "  The  Dublin  Method  of  Effecting  the  Delivery  of  the  Placenta." 
M  D.,  etc.      Dublin,  1900. 


By  Henry  Gellett, 


DELIVERY  OF  THE    PLACENTA   AND   MEMBRANES. 


1029 


3.  Digital  Extraction. — In  most  instances  of  retention  the  placenta  lies  loose 
in  the  uterine  cavity  or  is  only  slightly  attached  to  the  uterus.  In  such  cases, 
although  Credo's  method  of  expression  fails,  something  less  radical  than  the  in- 
troduction of  the  whole  hand  into  the  uterus  is  called  for  to  deliver  the  placental 
The  author  is  accustomed  to  resort  to  what  may  be  termed  digital  extraction  in 
these  cases.  After  proper  preparation  of  the  external  genitals  and  vagina,  the 
first  and  second  fingers  of  either  hand  are  introduced  into  the  vagina,  and  the 
other  hand  on  the  fundus  prolapses  the  uterus  upon  and  over  the  two  vaginal 
fingers.  The  placenta  is  now  seized  between  the  fingers,  and  by  combined  ex- 
pression and  traction  the  placenta  and  membranes  are  slowly  delivered  (Figs. 
1260,  1 261).     Anesthesia  is  rarely  necessary. 

4.  Instrumental  Extraction, — Removal  of  the  placenta  and  membranes  by 


Fig    1262. — Manual  Extraction  of  the  Placenta  by  the  Introduction  of  the  Whole 
Hand  into  the  Uterus,  Assisted  by  Suprapubic  Pressure  upon  the  Fundus. 


means  of  the  placental  forceps  possesses  no  advantages  over  digital  or  instru- 
mental curettage,  and  I  have  long  since  abandoned  this  method. 

5.  Manual  Extraction. — As  a  rule,  ether  or  chloroform  should  be  used.  The 
patient  is  placed  in  the  lithotomy  position,  the  external  genitals  are  thoroughly 
cleaned,  and  the  vulva  is  separated  to  its  widest  extent  with  one  hand.  The 
other  hand  in  the  shape  of  a  cone  (Fig.  11 14)  is  then  carefully  passed  into  the 
vagina.  The  hand  separating  the  vulva  is  now  transferred  to  the  fundus,  which 
it  firmly  grasps  (Fig.  1262).  Constrictions,  if  any  exist,  should  be  overcome  by 
gradual  dilatation  with  the  cone-shaped  hand.  Should  the  placenta  be  found 
free  in  the  uterine  cavity,  it  is  simply  grasped  and  removed.  If  adhesions 
are  present,  however,  the  placenta  is  best  separated  by  peeling  it  off  by 
means  of  the  fingers  from  above  downward  (Fig.  1262).  In  the  presence 
of  extensive  and  firm  adhesions  great  care  is  necessary  not  to  leave  too  much 


1030 


OBSTETRIC  SURGERY 


placental  tissue  behind,  and  not  to  use  the  finger-nails  too  vigorously  and 
thus  lacerate  the  uterine  walls  too  deeply.  In  firm  adhesion,  after  the  bulk  of 
the  placenta  is  removed,  the  placental  site  must  be  repeatedly  gone  over  with  the 
finger-tips  in  order  to  insure  the  complete  removal  of  all  placental  tissue.  (See 
digital  curettage,  page  1031.)  In  premature  cases,  and  occasionally  at  term,  the 
use  of  the  smooth  or  even  the  sharp  curette  will  be  found  necessary  to  clear  the 


Fig.  1263. — Instrumental  Curett- 
age OF  the  Puerperal  Uterus, 
WITH  A  Cautious  Up  Stroke 
OP  THE  Curette,  and  a  Firmer 
Downward  One. 


Fig.   1264. —  Fig.    1265. —  Fig.  1266. — Thim- 
SharpPuer-  Blunt  Puer-  ble    Curette, 
peral       Cu-  peral      Cu- 
rette. RETTE, 


uterus  of  debris.  The  author  has  never  found  that  the  placental  forceps  pos- 
sessed any  advantages  over  the  curette.  Following  the  operation  the  uterine 
cavity  should  be  freely  irrigated  with  a  i  per  cent,  solution  of  creolin  or  lysol, 
decinormal  salt  solution,  or  i  :  10,000  sublimate  solution.  Should  atony  and 
hemorrhage  persist  after  complete  emptying  of  the  uterus,  the  bleeding  is  treated 
as  in  ordinary  cases  of  post-partum  hemorrhage. 


OPERATIONS  FOR  THE  CORRECTION  OF  INJURIES.  1031 

6,  Digital  Curettage. — After  proper  cleansing  of  the  hands,  external  genitals, 
and  vagina,  the  os,  if  necessary,  is  either  digitally  or  instrumentally  dilated  to 
allow  the  passage  of  one  or  two  fingers.  The  first  and  second  fingers  of  either 
hand  are  then  passed  into  the  vagina  and  the  free  hand  upon  the  abdomen  pro- 
lapses the  fundus  upon  and  over  the  vaginal  fingers.  The  tips  of  the  fingers  are 
then  made  to  pass  over  every  portion  of  the  endometrium,  using  them  very  much 
as  we  would  the  blunt  curette  to  remove  all  placental  or  membranous  tissue.  The 
fingers  can  conveniently  be  used  as  a  pair  of  forceps  to  withdraw  loose  pieces  of 
debris  through  the  os  (Figs.  1261, 1054).    Anesthesia  can  often  be  dispensed  with. 

7.  Instrumental  Curettage. — The  patient  is  placed  in  the  lithotomy  position 
with  the  hips  drawn  well  over  the  edge  of  the  table.  Anesthesia  is  necessary 
and  ether  is  to  be  preferred,  especially  if  the  patient  is  somewhat  exhausted 
from  hemorrhage.  The  vulva,  lower  abdomen,  and  upper  thighs  are  thoroughly 
scrubbed  with  green  soap  and  water  and  afterward  with  sublimate  or  lysol 
solution.  The  vagina  is  then  cleansed  in  the  same  way.  A  soft,  five-inch 
jeweler's  brush  or  a  swab  of  cotton  or  gauze  upon  long  dressing  forceps  should 
be  used  for  the  vagina.  A  perineal  depressing  speculum  is  now  inserted  and 
the  cervix  seized  with  one  or  two  pairs  of  volsellum  forceps.  Much  traction 
should  not  be  made,  the  object  being  to  steady  the  uterus.  The  os  is  then 
dilated  with  a  steel  dilator  of  the  Goodell  type.  The  uterine  cavity  is  washed 
out  with  a  sublimate  solution  (i :  10,000)  or  a  lysol  solution,  2  per  cent.,  a  digital 
examination  followed  by  another  irrigation  is  made,  and  the  uterus  is  curetted. 
The  size  and  position  of  the  uterus  should  be  carefully  estimated  before  the 
curette  is  introduced,  and  it  may  be  necessary  in  rare  cases  to  bend  the  handle 
of  the  instrument  to  suit  the  utero-vaginal  axis.  The  curette  should  be  carried 
carefully  to  the  fundus,  since  perforations  are  usually  caused  by  carelessness  in 
this  respect.  The  downward  stroke  may  be  moderately  firm.  The  anterior,  pos- 
terior, and  lateral  surfaces  should  be  carefully  scraped,  especial  care  being  taken 
to  clear  the  comua  of  debris,  which  frequently  accumulates  in  these  situations 
(Fig.  1263).  The  operator  may  know  when  he  has  reached  the  uterine  wall  by 
the  characteristic  grating  sensation. 

Choice  of  Instruments. — Much  has  been  said  as  to  whether  the  sharp  or  dull 
curette  is  to  be  used.  It  will  often  be  best  to  use  both,  first  the  dull  curette  in 
order  to  remove  the  loosely  attached  decidua  and  placental  tissue,  and  later  the 
sharp  instrument  for  the  detachment  of  smaller  adherent  fragments  and  the 
thorough  cleansing  of  the  uterine  walls.  During  and  subsequent  to  the  operation 
the  uterine  cavity  is  freely  irrigated.  It  is  not  necessary  to  pack  the  uterus  or 
vagina  after  the  operation,  unless  this  procedure  is  called  for  by  severe  hemor- 
rhage or  atony  (see  page  885). 


(D)  OPERATIONS  FOR  THE  CORRECTION  OF 

INJURIES. 

I.   CELIOTOMY  IN  RUPTURE  OF  THE  UTERUS. 

See  Rupture  of  the  Uterus,  page  589. 


1032 


OBSTETRIC  SURGERY. 


II.   CELIOTOMY  FOR  SEPSIS  OF  THE  UTERUS. 

See  Fever,  page  757. 


Fig.    1267. — Repair  of    a    Deep  Laceration   of   the 
Cervix. 


III.    REPAIR  OF  INJURIES  TO  CERVIX,  VAGINA,  RECTUM, 
PERINEUM,  AND  CLITORIS. 

1.  Cervical    Lacerations. — The  varieties  of  these  lacerations  have  been  de- 
scribed on  page  593.     Some  writers  have  advised  the  immediate  repair  of  all 

cervical  lacerations,  but  it 
is  now  pretty  generally  con- 
ceded that  it  is  neither 
necessary  nor  safe,  since  it 
increases  the  danger  of  sep- 
sis and  has  no  compensa- 
tory advantages,  but  rather 
interferes  with  drainage. 
Very  deep  lacerations,  how- 
ever, that  cause  severe 
hemorrhage  and  favor  ex- 
tension of  infection  to  the 
parametrium  should  be 
promptly  sutured. 

The  instruments  needed 
are  two  pairs  of  volsellum 
forceps,  and  a  needle-holder 

and  large  curved  needles.     In  rare  cases,  as  in  cicatricial  fixation  of  the  cervix  or 

in  the  case  of  a  primipara  with  very  small  birth  canal,  a  large  speculum  may  be 

required.     The  patient  being  in  the  lithotomy  position,  the  uterus  is  depressed  by 

external    pressure  over  the   fundus.     The 

anterior  and  posterior  lips  are  then  seized 

by  the  volsellum  forceps,  which  assists  if 

necessary    in    drawing    down    the    cervix 

(Fig.  1267).     The  stitches  should  be  about 

half  an  inch  apart.     The  first  should  be 

above  the  angle  of  the  laceration.    In  some 

cases  a  single  stitch  is  sufficient. 

2.  Vaginal  Lacerations. — Lateral  and 
anterior  tears  of  the  vagina  should  be  re- 
paired in  accordance  with  the  general 
principles  laid  down  regarding  injuries 
of  the  pelvic  floor.  Vesical  and  rectal 
fistulcB  should  be  promptly  repaired  if  the 
extent  of  the  injury  can  be  defined.  In 
cases   of  sloughing,  however,  this   cannot 

be  done,  and  it  will  be  necessary  to  wait  for  the  secondary  operation,  which 
in  the  interest  of  the  patient  should  be  performed  as  soon  as  possible.  It  is, 
therefore,  of  the  greatest  importance  to  the  patient  that  an  exact  diagnosis 
should  be  made.     The  presence  of  vaginal  fistula  may  be  confirmed  by  injecting 


Fig.  1268.— Repaired  Lacerated  Cer- 
vix. Stitches  in  Place. — (From  a 
photograph  taken  at  the  Emergency 
Hospital.) 


OPERATIONS  FOR  THE  CORRECTION  OF  INJURIES. 


1033 


into  the  bladder  warm  milk  which  has  been  boiled,  or  some  sterilized  solution  of 
one  of  the  anilin  dyes  in  harmless  quantity.  Flatus  and  feces  escape  into  the 
vagina  if  the  rectum  has  been  penetrated ;  urine  if  the  fistula  communicates  with 
the  bladder.  The  immediate  operation  does  not  differ  from  the  secondary  opera- 
tion except  that  there  is,  of  course,  no  denudation. 

3.  Pelvic-floor  Lacerations. — The  term  "perineal  lacerations"  as  usually  em- 
ployed is  anatomically  incorrect,  since  it  is  made  to  include  lacerations  of  the 
posterior  vaginal  wall,  perineum,  and  rectum.  Since,  however,  lacerations  in- 
volving these  structures  frequently  occur  together,  and  since  the  operations  for 
their  repair  are  frequently  combined,  it  is  convenient  for  clinical  purposes  to  con- 
sider them  together  under 

three  degrees.    (See  Part  V,  />     'N       A 

page  595.)     First  Degree:  ,    \  ^N^^r> 

Superficial      perineal       or  '•■   "^^ 

perineo- vaginal  lacera- 
tions. These  consist  usu- 
ally of  a  tear  of  skin  and 
mucous  membrane,  and 
may  be  regarded  as  exten- 
sions of  the  tear  of  the 
fourchette  which  so  often 
occurs  in  first  labors  (Figs. 
1269,  1270).  Second  De- 
gree: Vaginal  or  vagino- 
perineal lacerations  which 
extend  more  deeply  but 
do  not  involve  the  sphinc- 
ter ani.  These  may  or  may 
not  involve  the  skin  sur- 
face of  the  perineum.  The 
former  is  most  frequently 
the  case  in  operative  de- 
liveries. Very  commonly 
the  internal  laceration 
takes  the  form  of  a  trans- 
verse tear  within  the  vagi- 
nal orifice  with  prolonga- 
tions which  extend  up  one 
or  both  sides  of  the  poste- 
rior column  (Fig.  1270). 
This  variety  of  laceration 
may  not  be  suspected  un- 
less the  vagina  is  examined  at  the  close  of  labor  (Fig.  1269).  Third  Degree: 
Vagino-perineo-rectal  lacerations  in  which  the  sphincter  ani  is  involved.  Tears 
of  this  degree  involving  the  sphincter  ani  and  rectum  extend  upward  for  a  vari- 
able distance,  and,  like  tears  of  the  second  degree,  are  prone  to  follow  one  or 
both  sides  of  the  posterior  vaginal  wall.  Very  rarely  the  column  is  divided  in  the 
median  line.  Central  perforations  of  the  perineum  or  pelvic  floor  may  occur. 
(See  Part  V,  page  597.)  In  central  perforations  the  fold  of  skin  at  the  perineum 
may  be  torn  away  by  the  shoulder  during  delivery,  the  resulting  laceration 
looking  like  one  of  the  second  degree: 

Reasons  for  hnmediate  Operation. — Superficial  tears  of  the  fourchette  which 


Fig.    1269. 


-First  Degree 


OR    Superficial    Perineo- 


vaginal Laceration  of  the  Pelvic  Floor.  Right 
Vaginal  Sulcus  only  Involved.  Stitches  for  Re- 
pair IN  Place.  Note  the  numerical  order  of  passing 
the  stitches. 


1034 


OBSTETRIC  SURGERY. 


usually  occur  in  first  labors  do  not  require  attention.  Larger  superficial  tears — 
e.  g.,  those  which  have  a  base  of  from  h  to  |  of  an  inch — may  become  infected,  or 
in  rare  cases  may  lead  to  the  formation  of  sensitive  scar  tissue  and  should  be 
sutured.  All  other  tears  should  be  immediately  sutured,  since  otherwise  not  only 
is  the  danger  of  sepsis  increased,  but  the  patient  may  be  a  life-long  invalid  as  the 
result  of  injury  to  the  pelvic  floor.  If  the  patient's  condition  is  such  that  the 
operation  is  deemed  unsafe,  e.  g.,  after  severe  hemorrhage,  or  if  the  laceration  is 
severe,  and  the  operator  distrusts  his  ability  and  needs  skilled  assistance,  it  may 
be  postponed  for  from  twelve  to  twenty-four  hours,  careful  asepsis  being  main- 
tained in  the  mean  time. 

General  Principles. — The  operator  should  use  great  care  as  to  asepsis,  but 

should  not  employ  chemical 
antiseptics.  He  should  clear 
the  field  of  operation  from 
blood  by  irrigating  with 
saline  solution  and  sponging 
with  sterilized  gauze,  and 
bring  the  parts  as  nearly  as 
possible  into  their  normal 
relations  by  means  of  ten- 
acula  in  order  to  appreciate 
the  extent  and  character  of 
the  injury.  He  should  aim 
to  secure  exact  approxima- 
tion of  denuded  surfaces  in 
their  normal  relative  posi- 
tions. He  should  snip  away 
with  the  scissors  necrosed 
tags  or  bruised  bits  of  tissue, 
and  leave  no  pockets  for  the 
collection  of  stagnant  secre- 
tions. This  is  to  be  avoided 
by  not  allowing  the  needle 
to  appear  in  the  wound,  or, 
when  the  Emmet  suture  is 
used,  by  entering  the  point 
again  in  the  deepest  part  of 
the  wound. 

Operation. — In  the  slight- 
er degrees  of  laceration  an- 
esthesia is  not  usually  neces- 
sary, the  tissues  being  benumbed  by  pressure,  and  the  patient  still  perhaps  par- 
tially under  the  influence  of  an  anesthetic.  In  the  severer  forms  in  which  careful 
suturing  is  required,  anesthesia  will  usually  be  needed,  and  if  such  a  rupture  occurs 
it  is  best,  if  an  anesthetic  has  been  administered  during  the  expulsion  of  the  head, 
to  continue  its  use  until  the  laceration  has  been  repaired,  thus  obviating  the 
necessity  of  re-anesthetizing  the  patient,  and  lessening  the  amount  of  the  anes- 
thetic to  be  administered.  (Compare  Management  of  Labor,  Part  IV.)  The 
patient  is  placed  in  the  lithotomy  position  with  the  hips  drawn  well  over  the 
edge  of  the  bed  or  table,  and  the  upper  part  of  the  vagina  is  temporarily  packed 
with  sterilized  gauze  to  check  the  flow  of  blood  and  enable  the  operator  to 
see  what  he  is  doing.     The  instruments  needed  are:   needle-holder;   small  and 


Fig.  1270. — First  Degree  or  Superficial  Perineo- 
vaginal Laceration  of  the  Pelvic  Floor.  Both 
Vaginal  Sulci  Involved.  Shows  Method  of  Pass- 
ing THE  Stitches  for  Repair.  Note  the  numerical 
order  of  passing  the  sutures. 


OPERATIONS  FOR  THE  CORRECTION  OF  INJURIES 


1035 


medium-sized  curved  needles ;  a  pair  of  scissors ;  a  speculum  or  retractor  for  the 
anterior  vaginal  wall  (in  tears  of  the  third  degree  it  is  well  to  have  two  retractors, 
one  for  each  side) ;  tenacula;  suture  material. 

A  needle-holder  is  not  absolutely  necessary  unless  the  laceration  extends  far 
up  into  the  vagina.  Retractors  may  be  improvised  from  bent  spoons.  A  single 
suture  with  the  ends  left  long  and  held  by  an  assistant  takes  the  place  of  a  tena- 
culum, and  ordinary  sewing-needles  or  darning-needles  sterilized  in  a  flame  may 
be  used  in  an  emergency.  Silk,  silkworm-gut,  catgut,  or  silver  wire  may  be  used. 
Catgut  is  preferable  for  the  vagina,  since  it  does  not  require  removal.  Silkworm- 
gut  is  preferred  by  many 
operators.  It  can  be  easily 
rendered  aseptic  by  boil- 
ing for  ten  or  fifteea  min- 
utes. It  is  especially  ser- 
viceable when  deep  su- 
tures embracing  a  large 
amount  of  tissue  are  to  be 
passed. 

First  Degree. — The  op- 
eration is  very  simple. 
The  sutures  are  passed  as 
in  Figs.  1269,  1270.  The 
labia  being  separated  by 
the  fingers  of  the  left  hand, 
the  wound  is  closed  from 
above  downward  by  inter- 
rupted sutures,  the  needle 
being  introduced  close  to 
the  upper  angle  of  the 
wound  near  its  margin, 
not  appearing  in  the 
wound  but  emerging  at  a 
corresponding  point  on 
the  opposite  side.  Two 
sutures,  with  perhaps  two 
or  three  additional  su- 
tures for  the  skin-surface, 
will  usually  be  sufflcient. 

Second  Degree.  —  The 
anterior  vaginal  wall  is 
drawn  up  by  a  retractor 
and  the  parts  are  tem- 
porarily restored  to  their  respective  positions  by  tenacula.  The  vaginal 
lacerations  are  sutured  from  above  downward  (Fig.  127 1).  If  there  are  two, 
one  on  each  side  of  the  posterior  column,  they  should,  of  course,  both  be  re- 
paired, but  care  should  be  taken  that  the  posterior  column,  often  bruised  and 
detached  from  below  upward,  is  left  in  its  normal  position  (Fig.  1271 ).  In  order 
that  the  lower  portions  of  the  wounded  surface  may  be  lifted  up  and  brought  into 
contact  in  the  same  relative  positions  which  they  previously  occupied,  the  Emmet 
suture  should  be  used.  In  this  method  of  suturing  the  needle  is  not  passed 
directly  across  the  wound  but  downward  until  it  appears  in  the  floor  of  the  lacera- 
tion, then  re-entered  and  carried  upward  again  until  it  appears  at  a  point  on  the 


^:^//\\\'-' 


Fig.  1271. — Second  Degree  or  Deep  Vagino-perineal 
Laceration  of  the  Pelvic  Floor,  not  Including 
the  Sphincter  Ani.  The  Laceration  in  this  Case 
Involves  the  Left  Vaginal  Sulcus.  Stitches  fok 
Repair  in  Place.  Note  the  numerical  order  of  pass- 
ing the  sutures. 


1036 


OBSTETRIC  SURGERY. 


opposite  side  of  the  laceration  corresponding  to  that  at  which  it  first  entered. 
The  first  suture  closes  the  upper  end  of  the  laceration.  "  The  sutures  below  this 
must  then  be  passed  with  the  two  distinct  objects  in  view:  of  grasping  the  torn 
muscular  tissue  on  the  lateral  wall  by  deep  suturing  and  of  exercising  a  definite 
lift,  each  suture  helping  to  lift  up  the  pelvic  floor."  They  should  be  about  one- 
half  inch  apart,  and  care  should  be  taken  not  to  pass  it  into  the  rectum.  After  the 
sulci  have  been  closed  in  the  manner  above  described,  the  remaining  denuded  area 
will  be  found  surprisingly  small.    It  may  be  closed  by  a  single  purse-string  suture, 

which  should  also  be  made 
to  transfix  and  hold  in  its 
proper  place  the  end  of 
the  posterior  column. 
The  suture  enters  the  skin 
surface  of  the  perineum 
and  emerges  at  a  corre- 
sponding point  on  the 
opposite  side.  In  place 
of  this  purse-string  suture 
two  or  three  interrupted 
sutures  may  be  used.  A 
few  superficial  sutures 
should  be  inserted  wher- 
ever necessary  to  secure 
accurate  coaptation. 

Third  Degree. — The 
results  of  this  variety  of 
laceration  are  so  deplor- 
able that  an  immediate 
operation  is  of  special 
importance.  ~  If,  how- 
ever, the  operator  dis- 
trusts his  own  skill  or  is 
without  suitable  instru- 
ments and  suture  mate- 
rial, it  is  better  to  delay 
the  operation  for  from 
twelve  to  twenty-four 
hours  until  he  can  obtain 
skilled  assistance.  The 
patient  being  in  the  lith- 
otomy position  and  the 
field  of  operation  being 
exposed  by  retractors,  one 
on  each  side,  the  rectal  tear  is  first  closed  from  above  downward  by  interrupted 
sutures  of  silk  and  fine  catgut  about  one-sixth  of  an  inch  apart  (Fig.  1272). 
These  are  passed  from  one-fifth  to  one-fourth  of  an  inch  from  the  edge  of  the 
mucous  membrane,  taking  up  just  enough  of  the  tissues  of  the  recto- vaginal 
septum  to  secure  a  good  hold.  If  catgut  is  used,  the  sutures  are  tied  in  the 
rectum  and  the  ends  cut  short.  If  silkworm-gut  or  other  non-absorbable 
material  is  used,  the  sutures  are  tied  in  the  rectum  and  the  ends  left  long  so 
as  to  hang  out  of  the  anus.  The  ends  of  the  sphincter  should  be  united  by 
two  or  three  extra  fine  catgut  sutures.     If  the  sphincter  has  been  badly  torn 


Fig.  1272. — Third  Degree  or  Vagino-perineo-rectal 
Laceration  of  the  Pelvic  Floor,  in  which  the 
Sphincter  Ani  is  Involved.  Shows  Method  of 
Passing  the  Sutures.  Note  the  numerical  order  of 
the  stitches,  and  that  9  transfixes  the  sphincter  muscle 
on  both  sides. 


OPERATIONS  FOR  THE  CORRECTION  OF  INJURIES. 


103' 


and  the  ends  have  retracted,  they  should  be  drawn  out  with  a  tenaculum  before 
suturing  and  the  extra  sutures  in  the  sphincters  should  be  reinforced  by  one  or 
two  sutures  of  silk  or  silkworm-gut,  which  should  be  passed  through  the  exter- 
nal skin  at  a  greater  distance  from  the  torn  ends  of  the  sphincter  and  should 
pass  above  the  angle  of  the  tear  and  emerge  at  a  corresponding  position  on 
the  opposite  side.  The 
laceration  is  thus  con- 
verted into  one  of  the 
second  degree,  the  treat- 
ment of  which  has  been 
already  described  (Fig. 
127 1 ).  If  the  vaginal 
laceration  extends  far  up 
into  the  vagina,  its  upper 
portion  may  first  be  su- 
tured, next  the  rectal  rent 
and  sphincter  repaired, 
and  the  operation  com- 
pleted as  above  described 
(Figs.  1272,  1273).  In 
the  rare  cases  of  central 
perforation  of  the  peri- 
neum already  described, 
the  anterior  portion  of  the 
perineum  should  be  divid- 
ed, since  it  is  of  no  ser- 
vice and  prevents  proper 
inspection  of  the  deeper 
part  of  the  wound.  The 
laceration  is  then  treated 
as  already  described. 

After-treatment.  — The 
knees  should  be  loosely 
bound  together  (Fig.  919). 
The  use  of  the  catheter 
should  be  avoided  if  pos- 
sible. Scrupulous  cleanli- 
ness of  the  external  geni- 
tals should  be  secured, 
and  after  urination  and 
defecation      the      parts 

should  be  washed  with  a  weak  sublimate  solution.  If  the  lochia  are  normal,  no 
douches  are  indicated.  The  bowels  should  be  kept  open  after  the  second  01 
third  day.  If  an  enema  is  necessary,  it  should  be  intrusted  only  to  an  experienced 
nurse.  Since  the  tube  has  been  passed  into  the  sutured  laceration,  it  should  be 
pressed  against  the  posterior  margin  of  the  anus.  If  a  vaginal  douche  becomes 
necessary,  the  same  care  should  be  used,  the  syringe  being  pressed  against  the 
anterior  vaginal  wall.  The  sutures  should  be  removed  about  the  eighth  or  tenth 
day. 


Fig.  1273. — -The  Rectal  and  Vaginal  Sutures  of  Fig. 
1274  ARE  Tied,  the  Former  in  the  Rectum,  Leav- 
ing ONLY  the  Two  Perineal  or  External  Sutures, 

10    AND    II,   AND  the  SpHINCTER  SuTURE  9   TO   BE  TiED. 


APPENDIX. 


HISTORY  RECORDS. 

In  Private  Practice. — I  am  in  the  habit  of  urging  upon  my  students  the  im- 
portance of  starting  some  method  of  history-taking  in  order  that  they  may  subse- 
quently profit  by  a  study  of  their  cases.  Should  the  physician  not  take  up 
some  methodical  system  of  recording  his  cases  at  the  outset  of  his  practice,  he  is 
not  likely  to  do  so  later.  Of  course,  it  is  not  always  pleasant  to  acknowledge  one's 
errors  upon  paper,  but  one  can  learn  as  much  or  more  from  a  subsequent  study 
of  such  errors  as  from  successes.  I  have  at  various  times  in  the  past  used  the 
ordinary  history  sheets  and  history  books  for  this  purpose,  but  experience  has 
proved  the  card  system  to  be  more  satisfactory,  because  simple,  orderly,  and  self- 


FiG.   1274. — Card  Index  Case  for  Obstetrical  Histories. 

indexing.  The  cards  I  use  are  of  standard  size  (6  X  6y|-  inches).  Such  cards  are 
elastic  and  portable  and  can  readily  be  used  at  the  bedside  or  operating  room, 
for,  when  doubled,  the  history  of  the  patient  can  easily  be  carried  in  the  pocket 
or  card-case.  Any  of  the  different  methods  of  indexing  the  cards  may  be  used. 
For  obstetric  cases  I  use  three  printed  cards:  The  first,  pregnancy  (Figs. 
1275  and  1276);  the  second,  labor  (Fig.  1277)  and  puerperium  (Fig.  1278);  and 
the  third,  a  diagnosis  card  (Fig.  1279),  which  is  practically  a  blank  and  is  used 
for  complications  and  where  the  first  two  cards  prove  insufficient  to  contain 
a  given  history.  My  index  cards  are  made  for  me  by  the  Globe-Wernicke  Co., 
380-382  Broadway,  New  York. 

The  observations  to  be  noted  under  pregnancy  (Figs.  1275  and  1276),  labor 
(Fig.  1277),  and  the  puerperium  (Fig.  1278)  have  been  carefully  selected,  and  are 
the  result  of  many  years'  experience  in  obstetric  history-taking.  Such  card- 
history  records,  of  course,  need  not  be  limited  to  obstetrics,  for  the  same  case 
with  the  blank  "diagnosis"  cards  (Fig.  1279)  may  be  applied  to  general  medicine 
and  surgery. 

1039 


1040 


APPENDIX. 


Method  of  using  the  History  Cards. — As  already  stated,  there  are  only  three 
printed  cards  for  each  case,  as  labor  and  the  puerperium  are  contained  upon  one 


JUn. 


PREGNANCY.  Diogm 

faddrtAi) (Phone) 


Date  of  exptcted  labor 


Age ^ »-.     Para /^ur*f_ 

ifenttrvation  ilmu.  j   . .,   , 

Family  hUtory „ , 


Peraimdl  history  [     /wi.f^/'f/^'Wfci*'*''!. 


__      .                               ,       rFulltrrm.    ImtrmiplrJ.    Manlti  e/~\ 

IWou.Mbo«  r.$^^^^i.^'<^^1.^M 

PrenouBWLervfHxam,  Ffl^SI-  ollSSf-zi;-..! 

EXAMINATION  or  mKaNANCv:  (DaU\                        BreattM  [<^^i!;^] 

rfuaJHi.      PrnnUlitm.      Fortml  krtri.      Crnfi.l 

r            Prrimm.    StcrrtmK.    Crrva.    CrreUal  C^mmI.    OimflUationi.            1 
VflUINAl    !'■«>" -W-«'-     PmnlMhia.     PaiiliBm.     FiUmMtrd  tw,m      b,rt.m      (TwfW  J 



Fig.  1275. — Pregnancy  Index  Card;  this  Side  of  Card  is  for  a  History  of  the  Case 
AND  THE  Examination  of  Pregnancy;  this  Card  also  acts  with  Others  Arranged 
Consecutively  as  an  Index  op  the  Dates  of  Expected  Confinements. 

card.  For  convenience  in  indexing  and  selecting,  I  use  three  colors — blue  for 
pregnancy,  salmon  for  labor  and  puerperium,  and  buff  for  the  diagnosis  or  blank 
card.    The  pregnancy  cards  I  keep  by  themselves,  in  the  proximal  end  of  the  case, 


URINE.        TREATIENT.        REIARKS. 
nalt 

i«»..,. 

"™;ii."' 

Fig.  1276. — Reverse  of  Pregnancy  Card;  upon  this  Side  of  the  Card  are  Recorded 
the  Results  of  the  Various  Urinary  Examinations  of  Pregnancy,  as  well  as 
Treatment  or  Remarks. 


until  finally  indexed,  and  they  constitute  during  this  time  an  index  of  cases  of 
expected  confinement.     Upon  seeing  a  case  of  pregnancy  in  the  ofhce  or  at  the 


APPENDIX. 


1041 


patient's  home,  the  pregnancy  card  is  made  out  and  returned  to  its  place  in  the 
box,  and  this  becomes  a  record  of  a  case  of  an  expected  confinement  (Fig.  1274) 


Xn. 


LABOR.  DiagnotU 


^   Child  \^' 


Trut  paint  began  at ___ 

Duration.  Ill  Sugt, . sad 

A7\ct»thaia  (m.tmi,irdSi»tn-  op 
Membrana  (Rufiurti  tpti»iM<u«aii/  m 

Praaitaiion. „    PotHion 

Placenta  [c^Jii"] 

PoBtpartum  douches 

Action  of  uterus  during  physicia 

Vaginal  examinations,  by.tphom  made,  and  A'c. . 

Temperature -„— , 


i Pulse Se»pr. Antepartum  douches  ^ 

d  siaft „     Total  duration  of  labor 


Perineum 

Hemorrhage  _ 


Pulac... 


_  [one  hqiff-  after  labor] 


Fig.  1277. — Labor  and  Puerperium  Card;  upon  this  Side  of  the  Card  is  Recorded 
THE  History  of  Labor;  Should  More  Room  be  Required  for  History  of  Com- 
plications OR  Operations,  a  Diagnosis  Blank  Card  (Fig.  1279)  is  Used  in  Addi- 
tion. 

Upon   the    receipt  of  the  first  specimen  of  urine,  the  analysis,  with  date,  is 
recorded  upon  the  back  of  the  card,  as  well  as  any  subsequent  treatment  or  re- 


mothcr:                                             puerperium.                cmho:                                                         ] 

... 

,UI«„T»., 

- 

J^i!,c 

:.i^t. 

."»  1  ::^.- 

""';:"' 

™    1  r4r. 

„,=-, 

z 

— 

— 

1 



— 

■— 

— 

_._ 



-- 





— - 

'"" 

"i^ 

— 

™. 

■- 

Remarks: 

™v.,c.u 

IMHINDTION    ON 0«Y    OF   PUCdPCIIIUII :     LSt'.P««—.  ■"«»'"««"' "•■'•»</"»'■■■         J 

cMd.  [""^.".zT"]                                                         ""^jj;-'^„"' 

Fig.   1278. — Reverse  of  Fig.  1277;  Record  of  Puerperium  and  Examination  of  the 
Patient  at  the  End  of  Puerperium  and  Attendance. 


marks  upon  the  case.     Upon  being  called  to  a  case  of  labor,  one  selects  the 
proper  pregnancy  card   and   a  blank  labor  card  to   take  with  him  to  the  case. 
66 


1042 


APPENDIX. 


During  or  after  labor,  the  labor  card  is  filled  in  and  left  at  the  case  for  the  nurse 
to  record  the  observations  of  the  puerperium  of  both  mother  and  child,  the 
pregnancy  card  being  returned  to  its  place  in  the  case. 

Should  the  labor  or  puerperium  prove  complicated,  requiring  more  space,  the 
history  is  abstracted  on  the  buff  diagnosis  card,  and  given  a  number  referring  to 
the  detailed  account  of  the  case,  written  on  the  usual  bedside  history  charts, 
which  latter  history  sheets  are  filed  in  large  letter-file  boxes.  The  buff  abstract 
card  is  then  indexed  alphabetically  with  the  other  cards. 


Fig 


1279. — Blank  Card  Ruled;  Used  as  Extra  Card  in  Pregnancy,  Labor,  or  Puer- 
perium, OR  AS  Index  Card  for  General  Non-obstetric  Subjects. 


At  the  completion  of  the  puerperium,  the  labor  and  puerperium  card  is  re- 
turned to  the  box.  At  the  end  of  the  year,  or  other  convenient  time,  all  cards 
belonging  to  a  given  case  are  fastened  together  with  a  brass  clip  and  indexed 
among  the  alphabetical  guides  at  the  distal  end  of  the  box  (Fig.  1274). 

Institutional  and  Educational. — I  append  a  serviceable,  convenient,  and  more 
elaborate  obstetric  history  chart  for  institutional  and  educational  work,  which 
is  successfully  used  at  the  Manhattan  Maternity  and  Dispensary,  New  York. 


]V[anl::ia.ttan  IVLaternity  and.  Dispensary, 

32T  East  60tln  Street, 

Diagnosis  NEW  YORK  CITY.  Confinement  No 

===:n=r=:=:  Outdoor  App.  No. 

GENERAL  HISTORY.      ^^'^"'^'"' 

Date  of  Labor 19.. 


Name Para Nationality Age 

Address House Floor Married,    Single,   Widow. 

Occupation (Husband's  Occupation Wages  per  week No.  in  Family employed  J  ^"^^ A 

Family  History Tuberculosis,  Syphilis. 

Personal  History  of  Rickets,  Syphilis,  Gonorrhoea,  Leucorrhoea,  Pelvic  Trouble;  Heart,  Lung,  and  Kidney  Disease 

{Adde7ida) . 

Last  Menstruation.  {;g^J5?y;,/_}  First  Day  of 19...  {^i;;^','^/;^/.}  Date  of  Quickening iq... 

Previous  Pregnancies,  Number Vomiting,  Headache,  Oedema Miscarriages  No 

Labor,  Difficult,  Instrumental,  Prolonged Puerperii,  Fever 

Present  Pregnancy,  Vomiting,  Headache,  Oedema,  Etc General  Condition 

Children,  Weight  at  Birth, No.  Living Health Causes  Death 


ANTEPARTUM     EXAMINATION,       ^ade    /  Before  Labor 

'  \   In Stage  of  Labor. 

EXTERNAL.  Dry  Labor. 

I    Intact  Membranes. 
Date  of  Examination 19 \   Ruptured  Membranes. 

General  Condition Lungs Heart 

Breast,  Nipples,  Lacteal  Capacity Abdomen   and   Uterus 

Fetus,   Size Location,  Head Back Small   Parts I  r,"*^'^'       .      ^'S^' 

1^  Movements,    Ao" 

(Above,']  (Rate 

Presentation, <      In.      J-Brim.    Position Foetal  Heart-: 

\Beloui  \  (Location    

Measurements,  Intercrestal inches,    Interspinous inches.  Intertrochanteric inches.   External 

R 
Conjugate inches.    Right  and  Left  Oblique^ 


.inches 


INTERNAL. 

External  Genitals  and  Vagina,  Perineum Cystocele,  Rectocele,  Discharge 

Cervix,    Position External   Os    |OP^"\  Internal  Osl   OP^"-, 

[Closed i    Closed 

Internal  Measurements,  PelvIs,   Diagonal   conjugate inches.    True   Conjugate inches 

Interischial inches.  Flexibility  of  Coccyx Abnormalities 

SUMMARY    OF    EXAMINATION. 

Size  of  Foetus,  Estimated  Size  of  Pelvis Probable  Character  of 

Labor Quantity  of  Liquor    Amnii,   Estimated 

Probable  Date  of  Labor, ,9 Presentation Position 

Abnormalities,  Plural  Pregnancies,  

Addenda 


Exam.  Phys. 

1043 


HISTORY  OF  LABOR. 


Time  of  Call A.  P.  M J9 Arrival A.  P.  M 19 Length  of  Gestation Weeks 

Patient,  General  Condition Before  Labor,  T P R Foetal  Heart 

Position  of  Parturient Antepartum  Douche,  |  ^.f^' 


Began  At, 

Duration, 

Uterine  Contraction, 


Hemorrhage, 


i  Source, 
(  Anioutit, 


FIRST  STAGE. 

A.  P.  M., 19... 

Hours, Minutes. 

SECOND  STAGE. 

A.  P.  M ,    19... 

THIRD  STAGE. 

A.  P.  M., ,    19... 

Hours, Minutes. 

Hours, Minutes. 

! 

• 

Total 

Cord  tied  before 
or  after  Lung 

(Intact, 
t\Qxa\ir?me.s  A  Ruptured,     . 
yDeliveiy, 

vagina,    {g;^^:'^^. 
Presentation.  {^^S;.., 


Delivery      I  Ope'ative, 
ueuvery,    |  spo7itaneous 

r-        •      r  Dilatation, 
Cervix,  I  j.^^,.^^      :  .    . 

(  Condition, 
Perineum, <  Management, 
(_  Tears, 
(Prolapsed, 
CotCl,<  Management    .     . 
\About  Neck, 

Manipulations,  .    . 


Medication,  {^ni'sthesia, 

Bladder==Rectum,      .     .     . 

During  Labor==Patient's  T P R and  Foetal  Heart. 

Placental  Delivery, Method Time A.P.M 

Actual  Presentation Actual  Position xotai  Duration  of  Labor Hrs m 


.19 Post  Partum  Douche  |  (_:j^^i,[g 


Uterus  Tonicity Height  above  Pubes inches. 

(  Taken  one  hour  after  labor.) 

Complications  and  Operations 


Delivered  by. 


M.D. 


Performed  by  Dr 

CHILD'S    RECORD. 

Date  of  Birth A.  P.M 19 Sex Maturity Weeks.    Weight Lbs Ozs. 

Total  Length inches.    Living,  Stillborn,  Macerated.     General  Condition 

.         (Cyanotic,')  (Artificial,  "l  Method 

Circulation-;  iVbrwa/,    yPulse  Temperature Respiration <  Spontaneous,     > 

\^AncE7nic,)  [  Resuscitatioti, )  Time  Required... M 

^         -c          J                   fSize,  (Defecated,     i'es,  A'O. 

caput  uucceaaneum,  |  Location, Moulding Size  of  Fontanelles \  Micturated,  I'es,  No. 

Anomalies,  Injuries, Umbilicus,  Genitals,  Eyes,  Ear,  Nose,  Mouth,  Skin 

Circumferences,  Blsacromial, inches.     Suboccipito==Bregmatic Inches. 

Diameters,  Biparletal Inches.    Suboccipito==Bregmatic Inches.    Occipito==Mental Inches. 

Bisacromial Inches.    Length,    Cord Inches,    Insertion 

Placenta,    \^r°"^^K\^t     I    Size Form  Anomalies 

I  Incomplete,  J 

Membranes,  \'j°^conMete  }   ^'"^  °^  Rupture Anomalies Plural  Births,  Placenta, 

Membranes,  Cord 

1044 


DAILY  RECORD  OF  CHILD. 

Name  of  Child Confinement  No Sex 

Weight  at   Birth Lbs Ozs.     General  Condition Nouiiblicd Color,  Cry 

Anomalies,  Injuries Has  ''atient  |  ^'^"^^^'^^^^ 

The  Babies'  Temperature,  Pulse,  and  liespirution  taken  only  where  specially  indicated. 


DATE. 

1 

DAY. 

DAY  OF  BIRTH. 

FIRST. 

SECOND 

THIRD 
DAILY 

VISITS. 

A.M.  VISIT  1  P.M.  VISIT. 

A.  M.  VISIT  1  P.  M.  VISIT 

A.  M.  VISIT  1  P.  M.  VISIT 

BLEEDING, 
HEALED, 
CORD    OFF 

UMBILICUS,     PUS. 

QUALITY, 
QUANTITY 
DIET,     NURSING. 

NUMBER 
STOOLS       COLOR. 

WEIGHT. 

j 

VOMITING 

1 

TEMPERATURE. 

PULSE. 

1 

RESPIRATION. 

COLOR, 
SKIN,       ERUPTION, 

EYES,    DISCHARGE. 

GENERAL 
CONDITION. 

TREATMENT. 

ATTENDANT'S   NAME. 

DATE. 

1 

DAY. 

FOURTH 

FIFTH 

SIXTH 

SEVENTH 

EIGHTH 

NINTH 

VISITS. 

DAILY 

DAILY 

DAILY 

DAILY 

DAILY 

DAILY 

BLEEDING 
PUS 

CORD   OFF 
UMBILICUS,     HEALED. 

QUALITY, 
DIET,    QUANTITY, 
NURSING. 

COLOR 
STOOLS,        NUMBER. 

VOMITING. 

WEIGHT. 

TEMPERATURE. 

PULSE. 

RESPIRATION. 

j 

COLOR, 
SKIN,     ERUPTION. 

■ 

EYES,     DISCHARGE. 

! 

GENERAL 
CONDITION. 

TREATMENT. 

ATTENDANT'S 
SIGNATURE. 

Remarks- 


EXAMINATION  ON DAY  AFTER  BIRTH 19 ,  (This  E.xamination  is  made  at  last  visit.) 

General  Condition Umbilicus Eyes Skin Weight Lbs Ozs. 

I'   Good, 
]    Fair, 
"S    Poor, 
I    Critical. 


Died,  Discharged,  or  Transferred  (to hospital)  On 19 Condition 


Remarks,  Artificial  Feedinar- 
Urine  Reports,  Mothers,...'... 


1045 


PUERPERIUM. 
DAILY  RECORD  OF   MOTHER 


DATE. 

DAY. 

LABOR  DAY 

FIRST 

j         SECOND 

A.  M.  VISIT  1  P.M.  VISIT 

THIRD 

VISITS. 

A.M.  VISIT  1  P.M.  VISIT 

A.M.  VISIT  1  P.M.  VISIT 

DAILY 

CONDITION, 
SECRETION 

BREASTS,      NIPPLES. 

CHARACTER, 
ODOR, 
LOCHIA,    QUANTITY. 

CONDITION 
FUNDUS,     HEIGHT. 

CHARACTER 
STOOLS,           NUMBER. 

PULSE. 

1 

■    1 

TEMPERATURE. 

1 

I 

RESPIRATION. 

1 

URINE,    QUANTITY. 

DIET. 

GENERAL  CONDITION. 

TREATMENT. 

ATTENDANT'S   NAME. 

DATE. 

DAY. 

FOURTH 

FIFTH 

SIXTH 

SEVENTH 

EIGHTH 

NINTH 

VISITS. 

DAILY 

DAILY 

DAILY 

DAILY 

DAILY 

DAILY 

CONDITION, 
SECRETION, 

BREASTS,     NIPPLES. 

CHARACTER 
ODOR 
LOCHIA,             QUANTITY. 

CONDITION, 
FUNDUS,            HEIGHT. 

CHARACTER, 
STOOLS,             NUtWBER. 

PULSE. 

TEMPERATURE. 

1 

RESPIRATION. 

'     1 

URINE,       QUANTITY. 

1 

DIET. 

1 

GENERAL  CONDITION. 

i 

TREATMENT. 

ATTENDANT'S   NAME. 

Features  of  Puerperium. 


EXAMINATION  ON DAY  AFTER  LABOR 

Uterus,  Size Position Sensibility... 

Perineum,  Condition Cystocele,  Rectocele,  Rectal 

Cervix Lochia,  Quantity 

Breasts Nipples Remarks. 


19 ,   (Made  at  La.st  Visit) 

Mobility 

...Continence,  Prolapse 

.Color Odor 


Discharged,  Died,  or  Transferred  (to hospital)     On. 


I    Good, 

.19 Condition    v   Fair, 


Total  Days  Treated. 


Signature. 
1046 


Poor, 
Critical. 

M.  D. 


INDEX. 


Abdomen,  changes  in,  in  pregnancy,  125, 
in  puerperium,  678 ;  evisceration  of,  960 ; 
examination  of,  in  pregnancy,  154-162; 
fetal,  enlarged,  cause  of  dystocia,  620; 
formation  of,  60;  pendulous,  274,  678; 
pigmentation  of,  125;   striae  of,  125. 

Abdominal,  binder  in  puerperium,  695; 
muscles,  action  of,  in  labor,  428;  dias- 
tasis of,  711;  section  (see  Lapar- 
otomy);  tumors,  282. 

Ablatio  placentae,  224. 

Abortion,  after-treatment  of,  361;  age  of 
patients  in,  346;  and  premature  labor, 
induction  of,  888-895;  S'^d  sexual 
intercourse,  relation  betv/een,  188; 
anemia  after,  356;  artificial,  in  pelvic 
deformity,  656;  cause  of  pelvic  disease, 
39;  causes  of,  in  ovum  and  embryo, 
348,  349;  local,  349;  systemic,  348; 
clinical  phenomena  of,  350;  complete, 
343;  concealed,  343;  concealed,  diagno- 
sis of,  354;  criminal,  344,  353;  curet- 
tage in,  358,  361;  definition  of,  342; 
diagnosis  of,  352,  354;  differential 
diagnosis  of,  354;  duration  of,  352; 
endometritis  after,  356;  ergot  in,  361; 
etiology  of,  348;  frequency  of,  345; 
hemorrhage  in,  354;  habit,  350,  357; 
in  cholera,  257;  in  erysipelas,  336; 
in  measles,  336;  in  pneumonia,  337; 
in  retro-displacements  of  the  uterus,  349 ; 
i n  scarlatina,  336;  in  typhoid  fever,  336; 
incomplete,  343;  diagnosis  of,  353; 
indications  for  induction  of,  888,  889, 
890;  induced,  343;  inevitable,  343; 
malignant  disease  after,  356;  maternal 
causes  of,  348;  membranes,  retention 
of,  in,  351;  methods  of  inducing,  891- 
895;  missed,  343,  368;  month  of  gesta- 
tion in,  348;  parity  of  patients  in,  347; 
pathology  of,  344;  paternal  causes  of, 
347;  polypi  after,  356;  prophylaxis  of, 
357;  prognosis  of,  354;  relative  fre- 
quency of,  349;  septic  infection  in,  355  ; 
sterility  after,  356;  symptoms  of,  350- 
352;  tetanus  following,  355;  therapeutic, 
in  pelvic  deformity,  675;  threatened, 
diagnosis  of,  352;  treatment  of,  357- 
361. 
Abscess,  mammary,  in  pregnancy,  291;  m 
newly  born,  851;  of  fixation,  in  puer- 
peral infection,  752;  puerperal  metasta- 
tic, 738;  retropharyngeal,  in  newly  born, 
844;   submammary,  in  puerperium.  767. 


Acanthopelys,  638. 
Accidents  in  pregnancy  ,369,370. 
Accouchement    forc6,    964;     in    eclampsia. 
312-314;    in  hemorrhage,  228;    in  pla- 
centa praevia,  222. 
Acetabulum,  union  of  parts  of,  376. 
Acetonuria,  in  pregnancy,  320;    in  puerper- 
ium, 320. 
After-birth.    (See  Placenta.) 
After-coming    head,    cephalotribe    to,    955, 
cranioclasis    in,     946;      extraction    of, 
974-980;    by  forceps,  979,   1003,   1004; 
by  Mauriceau  method,  978;    by  Prague 
method,     979;      by     Smellie     method, 
977;      by    Smelhe-Veit    method,     978; 
by  Wigand-Martin  method,  978. 

After-pains,  674;    treatment  of,  691. 

Agalactia,  760. 

Age,  for  establishment  of  menstruation,  21  ; 
influence  of,  on  primiparity,  666;  on 
progeny,  36;  of  fetus,  calculation  of,  83- 
88. 

Albuminuria,  effect  of,  on  newly  born,  809; 
in  eclampsia,  308;  in  elderly  primipara?. 
666;  in  multiple  pregnancy,  144;  in 
pregnancy,  117,  319;  in  puerperium, 
676. 

Alcohol,  in  acute  infection,  817;  in  eclampsia, 
300;  in  endometritis,  753;  in  erysipelas 
of  newly  born,  846;  in  intrauterine  ir- 
rigation, 883;  in  irrigation  of  septic 
uterus,  753;    in  pregnancy,  186 

Alcohohsm,  effect  of,  on  fetus,  260;  on 
newly  bom,  809:  on  spermatozoa,  28; 
in  pregnancy,   186. 

Alimentary  canal,  origin  of,  61. 

Alimentary  tract,  diseases  of,  in  fetus,  263; 
in  pregnancy,  321-324. 

AUantois,  68;    origin  of,  61. 

AlHs  inhaler,  867,  989. 

Alopecia  in  pregnancy,  339. 

Amnion,  66;  anomalies  of,  201-203;  dropsy 
of,  204;  in  twin  pregnancy,  142'. 
secretion  of,  66-68. 

Amniotic  fluid.      (See  Liquor  amnii.) 

Amputation,  fetal,  from  amniotitis,  202; 
of  fetal  parts  to  effect  delivery,  961. 

Anasarca,  fetal,  270,  809;  in  newly  born,  839. 

Anemia,  after  abortion,  356;  from  post- 
partum hemorrhage,  treatment  of,  584; 
in  etiology  of  accidental  hemorrhage. 
225;  in  pregnancy,  117;  in  puerperium, 
714;  pernicious,  an  indication  for  pre- 
mature delivery,  890;  pernicious,  in 
1  pregnancy,  328;    puerperal.  714.  768. 


1047 


1048 


INDEX. 


Anesthesia,  in  embryotomy,  944,  in  heart 
disease  of  pregnancy,  326;  in  labor 
479,  482,  490,  568,  865,  in  pelvic  floor 
operation,  1034;  spinal,  in  labor,  868; 
in  threatened  rupture  of  the  uterus,  589, 

Aneurism  in  pregnancy,  327. 

Ankylotic  pelvis,  626. 

Annular  placenta,   209. 

Anteflexion  of  pregnant  uterus,  274. 

Antenatal,  affections,  extending  into  extra- 
uterine Ufe,  807-812,  cutaneous  dis- 
eases, 267,  diseases  of  fetus,  255-272, 
807-812,    pathology,  242. 

Ante-partum  hemorrhage,  causes  of,  371. 

Anterior  parietal  presentation,  518. 

Antero-posterior  diameter,  of  pelvic  cavity, 
383;  of  pelvic  outlet,  166,  384. 

Anteversion,  of  uterus,  effect  of,  on  fetus, 
271;    of  pregnant  uterus,  274,275. 

Anthrax,  in  pregnancy,  258;    of  fetus,  258. 

Antipyrin  in  labor,  867. 

Antiseptics,  chemical,  151,  152;  in  labor, 
148;  in  treatment  of  puerperal  infection, 

754.  .  ,  .  ^ 

Antistreptococcus  serum,  m  puerperal  miec- 
tion,  751. 

Antitoxin  in  tetanus  of  newly  born,  847. 

Anuria  in  prematurity,  868. 

Anus,  formation  of,  58 ;  laceration  of  sphinc- 
ter of,  1036. 

Aphasia,  puerperal,  771;  in  puerperal  throm- 
bosis and  embolism,  768. 

Aphthae  of  newly  born,  847. 

Apoplexy,  cerebral,  at  birth,  823;  diagnosis 
of,  from  eclampsia,  307;  fetal,  812; 
in  pregnancy,  333;  of  placenta,  229- 
231,  345;  of  placenta,  cause  of  ante- 
partum hemorrhage,  372;  cause  of 
fetal  death,  272;  of  decidua,  195. 

Appendicitis  in  pregnancy,  324,  370. 

Appetite,  in  pregnancy,  115;  in  puerperium, 
676. 

Arm,  delivery  of  extended,  in  breech  pres- 
entation, 975;  dorsal  displacement  of, 
521;  in  breech  extraction,  975;  paraly- 
sis of,  826;  prolapse  of,  520;  repo- 
sition of  prolapsed,  521;  prolapse  of, 
in  shoulder  presentation,  shng  in,  1009; 
treatment  of,  in  breech  presenta- 
tion and  breech  extraction,  522;  treat- 
ment of,  in  cephalic  presentation,  521. 

Arterial,  infusion  of  salt  solution,  862,  ten- 
sion in  labor,  431. 

Arteries,  curling,  71;  fetal,  81,  82;  primary 
thrombosis  of  pulmonary,  in  puerperium , 

776. 

Artery,  ovarian,  changes  of,  m  pregnancy, 
108;  uterine,  changes  of,  in  pregnancy, 
107. 

Articulations,  anomalies  of  pelvic,  710; 
pelvic,  in  puerperium,  677. 

Artificial  feeding,  788-794;  tabular  guide 
for,  792. 

Artificial  respiration  in  asphyxia  neona- 
torum, 819-823. 

Ascites,  abdominal,  diagnosis  of,  from  hy- 
dramnios,  207;  and  pregnancy,  co- 
existence of,  136;  diagnosis  of,  from 
pregnancy,  135;  evisceration  in  fetal, 
960;  of  fetus,  263;  of  newly  bom, 
809. 

Asepsis,  in  labor,  464;    in  puerperium,  689, 


749;  in  third  stage  of  labor,  4^1; 
obstetric,  148;  of  patient,  physician 
and  accessories  in  1  elation  to  puerpe- 
rium, 749. 

Asphyxia,  neonatorum,  812-823;  etiology  of 
815;  treatment  of,  817-823;  varieties 
of,  813. 

Aspiration  pneumonia,  832. 

Asthma  in  pregnancy,   332. 

Atelectasis,  of  lungs  of  fetus,  779;  of  newly 
born,  814,  815,  838,  839. 

Atmocausis  in  septic  endometritis,  858. 

Atresia,  of  vagina  a  cause  of  dystocia,  611. 

Atrophy,  of  decidua,  196;  of  placenta,  209; 
of  uterus,  during  lactation,  709. 

Attitude  of  fetus,   420. 

Auscultation,  124,  143. 

Avulsion  of  fetal  extremities,  560. 

Axis  of  pelvic  cavity  387 ;  of  uterus,  changes 
in,  in  pregnancy,  103. 

Axis-traction  forceps,  998-1002. 

B. 

Baby's  outfit,  466. 

Bacillus,  coh  communis,  in  puerperal  peri- 
metritis, 732;  of  diphtheria  in  puerpei al 
infection,  740;  vaginas,  of  DOderlein, 
149. 

Bacteria,  effect  of  labor  on  genital  and 
perigenital,  716;  harmful  in  milk, 
prevention  of,  789;  in  puerperal  septi- 
cemia, 741;  migration  of  vaginal  in  la- 
bor, 716;  pathogenic  passage  of  from 
mother  to  fetus,  68. 

Bacteriemia,  740;  antepartum,  713;  puer- 
peral, 748;  puerperal,  pure,  741; 
with  toxemia,  puerperal,  741. 

Bacteriology,  of  genital  tract,  716;  of  puer- 
peral infectious  endometritis,  722;  of 
puerperal  morbidity,  739;  of  vagina  in 
pregnancy, 148, 149. 

Bag,  obstetric,  466-469 ;  of  waters,  at  birth, 
66,  rupture  of,  434;  sausage-shaped 
protrusion  of,  888. 

Ballottement,  in  pregnancy,  128,  132;  ab- 
dominal, in  pregnancy,  125. 

Bandl's  ring,    402. 

Barnes'  bag  in  delayed  labor,  573;  water- 
bag,  905,  906. 

Baudelocque's  diameter,  162,  164. 

Bed,  preparation  of,  for  labor,  471. 

Binder,  abdominal,  in  pregnancy,  187,  in 
puerperium,  496;    mammary,  766,  767 

Births,  percentage  of  premature,  800. 

Bladder  and  rectum,  distended,  cause  of 
dystocia,  613,  614. 

Bladder,  care  of,  in  puerperium,  691,  692; 
changes  in,  in  pregnancy,  113,  114,  130, 
diagnosis  of  distended,  from  pregnancy, 
134,  137;  distention  of,  in  fetus,  267; 
in  puerperium,  679;  fetal,  distended, 
evisceration  in,  960;  malformation  of, 
287;    irritability  of,  in  pregnancy,  316. 

Blastoderm,  53. 

Blindness,  in  puerperal  thrombosis  and  em- 
bolism, 768. 

Blood,  changes  in,  in  pregnancy,  117,  188, 
328;  clots,  puerperal  hemorrhage  from 
retention  of ,  701;  count  in  septicemia, 
741;  in  puerperium,  677,  739-742, 
768;   of  newly  bom.  783;     states,  com- 


INDEX. 


1049 


posite,  in  septic  puerperae,  742;  tumor 
(see  Hematoma);  velocity  of  fetal  cir- 
culation   of,    79. 

Blood-vessels,  diseases  of,  in  pregnancy, 
326,  327;  of  uterus,  changes  in,  in 
pregnancy,  106-108;  origin  of,  60,  78; 
pelvic,  400. 

Blunt  hook,    1009. 

Body  cavity,  60. 

Bones,  formation  of,  58;    pelvic,  375. 

Boric  acid  solution,  in  aphthae  of  newly 
born,  847;  in  catarrhal  conjunctivitis, 
834;  in  fissured  nipples,  759,  762;  in 
gonorrheal  stomatitis,  837;  in  hemor- 
rhage from  genitals  in  female  infants, 
850;  in  ophthalmia  neonatorum,  835; 
in  puerperal  cystitis,  754;  in  umbilical 
sepsis,  843. 

Bottle,  feeding,  care  of,  793. 

Bowel  excretion  of  fetus,  79. 

Bowels,  care  of,  in  pregnancy,  186;  in  puer- 
perium,  676,  692. 

Brachial  palsy,  from  injury  in  labor,  826, 
827. 

Bradycardia  in  puerperium,  674. 

Brain,  congestion  of,  in  pregnancy,  332; 
diseases  of,  in  pregnancy,  332,333;  origin 
of,  61 ;  traumatism  of,  at  birth,  823,  824. 

Braun's,  blunt  hook,  956,  957,  cranioclast, 
947,  948;    decollator,  957. 

Breasts,  and  nipples,  care  of,  in  puerper- 
ium, 692,  and  pelvic  organs,  relation 
between,  114,  115;  anomalies  of,  759; 
areola  of,  115 ;  areolar  inflammation 
of,  during  puerperium,  761;  caked, 
761;  care  of,  in  nursing,  692;  care 
of,  when  nursing  is  contraindicated , 
693;  in  pregnancy,  187,  in  puerperium, 
692;  changes  in,  in  pregnancy,  114,  115, 
126,  187;  congestion  and  engorgement 
of,  761,  a  cause  of  hyperthermia,  744; 
diseases  of ,  in  puerperium,  761-768;  in- 
flammation of,  762  ;  of  newly  born,  784 ; 
sensations  in,  in  pregnancy,  114,  115, 
striae  of,  114;  supernumerary,  759. 

Breech,  and  face,  differential  diagnosis  of, 
in  pelvic  presentation,  536;  arrest  of, 
above  pelvic  inlet,  968;  at  inlet,  968- 
971,  in  pelvic  cavity,  971-973;  ex- 
traction, 968-974,  dangers  of,  968, 
by  forceps,  971,  by  fillet,  971,  by  blunt 
hook,  971,  manual  method  of,  969, 
time  limit  of,  974,  traction  upon  a 
leg  brought  down,  969;  impaction  of, 
in  the  pelvic  cavity,  973;  presentation, 
527-538.     (See    Pelvic    presentation.) 

Bregma,  410,  411;  brow,  and  face  presenta- 
tion, manual  correction  of,  91 1-9 14; 
presentation,  500. 

Breisky's,  cephalotribe,  953,  method  of  bi- 
manual compression  of  the  uterus,  584, 
method  of  measuring  the  antero-pos- 
terior  diameter  of  pelvic  outlet,  166. 

Bright's  disease,  chronic,  effect  of,  on  preg- 
nancy and  fetus,  316. 

Broad  ligaments,  changes  in,  in  pregnancy, 
109. 

Brow,  fetal,  409;  permanent  posterior  rota- 
tion of,  in  labor,  505,  506;  presenta- 
tion, 503-508. 

Bruit,  placentaire,  in  pregnancy,  124; 
uterine,  in  pregnancy,  124. 


Buhl's  disease,  851. 

Byrd's  method  of  artificial  respiration,  819, 
823. 

C. 

Caesarean  section,  1011-1025;  after  vagino- 
fixation, 601 ,  in  accidental  hemorrhage, 
228;  in  cancer  of  uterus,  610;  in  case 
of  monsters,  561 ;  in  cornual  pregnancy, 
36S;  in  eclampsia,  313;  in  funnel- 
shaped  pelves,  623;  in  kyphosis,  646; 
in  myoma  of  uterus,  604;  in  Naegele's 
pelvis,  626;  in  obstruction  of  vagina, 
612,  in  ovarian  tumor.  604,  605;  in 
pelvic  deformity,  656,  657,  658,  659, 
660,  663,  664;  in  pelvic  tumors,  638;  in 
persistent  mento-posterior  positions, 
652;  in  pregnancy  after  ventrofixation, 
601;  in  Robert's  pelvis,  626;  inshoulder 
presentation,  544;  in  threatened  rup- 
ture of  uterus,  589;  in  tumors  caus- 
ing absolute  obstruction  to  delivery, 
602;  on  the  dead  and  dying,  1025; 
vaginal,  in  occlusion  of  external  os,  609 

Calcareous  degeneration,  of  placenta,  235. 
of  umbilical  cord,  240 

Calcification  of  fetus,  306. 

Calculi,  placental,  235;  vesical,  in  preg- 
nancy, 318,  cause  of  dystocia,  615. 

Canal,  alimentary,  formation  of,  57,  58; 
neurenteric,  54;  parturient,  description 
of,  400—408. 

Cancer,  cause  of  intra-partum  hemorrhage, 
671;  in  menopause,  39;  in  pregnancy 
263;  indication  for  prevention  of  re- 
production, 38 ;  of  cervix,  cause  of  ante- 
partum hemorrhage,  3  7  2 ;  of  uterus,  cause 
of  dystocia,  610,  treatment  of,  610 
pelvic,   638;    syncytial,   196. 

Cancerous  cachexia,  effect  of,  on  fetus,  263, 
on  newly  born,   809. 

Cancrum  oris  of  newly  bom,  843. 

Caput,  obstipum,  832,  succedaneum,  437 
452,  453,  830,  831. 

Carbolic  acid,  as  an  antiseptic,  152 ;  m  endo- 
metritis, 753 ;  in  phlegmasia  alba  dolens 
736;  in  vaginal  and  intrauterine  in- 
jections, 882. 

Carcinoma.      (See  Cancer.) 

Cardiac  diseases,  dystocia  due  to,  668;  effect 
of,  on  fetus,  263;    in  pregnancy,  263. 

Caries  of  teeth,  in  pregnancy,  322. 

Cartilage,  origin  of,  60,  62. 

Caruncular  formations  after  labor,  678. 

Casein  of  milk,  789. 

Castration,  indicated  in  rudimentary  uterus, 
285;  in  osteomalacia,  342. 

Catheterization,  887;  in  labor,  614;  in  puer- 
perium, 692,  706;  in  urinary  retention 
in  pregnancy,  318;  of  uterus  (Krause's 
method),  891. 

Celibacy,  advisable  in  case  of  pelvic  de- 
formity, 656;    pelvic  disorders  due  to. 

Celiotomy.     (See  Laparotomy.) 

Cellular  tissue  of  pelvis,  399. 

Cellulitis,  puerperal,  729,  737. 

Centers  of  ossification  as  sign  of  maturity  of 

fetus,  85,  88. 
Cephalhematoma,  830. 
Cephalometry,  180-185. 


1050 


INDEX. 


and    cranioclast    com- 


Cephalotomy,  955. 

Cephalotribe,    951, 
pared,  952. 

Cephalotripsy,  951-955. 

Cerebral  diplegia  of  fetus,  266. 

Cervical  canal,  9 1 ;  changes  in,  in  pregnancy, 
91,  147;  shortening  of,  91. 

Cervix,  affections  of,  cause  of  ante-partum 
hemorrhage,  371,  372;  bimanual  dilata- 
tion, indications  for,  898,  899;  canal  of, 
in  pregnancy,  9 1 ;  condition  of,  in  men- 
struation, 2 1 ;  consistency  of,  in  preg- 
nancy, 89;  deviation  or  malposition  of, 
cause  of  dystocia,  608;  dilatation  of, 
403;  dilatation  of,  instrumental,  902- 
906;  dilatation  of,  in  labor,  435,  in 
primiparse  and  multiparae,  403 ;  dilata- 
tion of,  manual,  895-902;  incisions  of, 
907;  in  puerperium,  678;  inflamma- 
tion of,  in  pregnancy,  371;  lacerations 
and  contusions  of,  592;  rigidity  of,  606; 
softening  of,  in  pregnancy,  123. 

Chamberlen's  forceps,  983. 

Champetier  de  Ribes'  bag,  894,  904,  in 
delayed  labor,  573,  in  placenta  prasvia, 
223. 

Child.     (See  Newly-born  child.) 

Chill,  in  puerperal  infection,  75;  physiolog- 
ical, after  labor,  440;  post-partum. 
673;  in  puerperal  perimetritis,  735;  in 
pyemia,  741;  in  sapremia,  738,  in  sep- 
ticemia, 741. 

Chloasmata  of  pregnancy,  117,  130. 

Chloral  in  eclampsia,  311;  in  labor,  867,  868 ; 
in  tetanus  of  newly  born,  847. 

Chlorine  water  in  puerperal  infection,  754. 

Chloroform,  administration  of,  866;  and 
ether;  choice  between,  867;  in  con- 
vulsions of  infants,  855;  in  labor,  480, 
482;  in  labor,  fetal  asphyxia  from,  261; 
in  manual  extraction  of  placenta,  1029; 
transmission  of,  from  mother  to  fetus, 
67.    _ 

Cholera,  in  pregnancy,  257;  puerperal,  738. 

Chorda,  56. 

Chorea,  in  pregnancy,  335;   of  fetus,  266. 

Chorio-epithelioma  malignum,  196. 

Chorion,  63,  68;  diseases  of,  198—201; 
fibromyxomatous  degeneration  of,  201; 
formation  of,  57;  frondosum,  69;  in- 
flammation of,  201;   teve,  69. 

Chyluria  in  pregnancy,  320. 

Circular  vein  of  placenta,  71. 

Circulation,  changes  in  fetal,  780;  charac- 
teristic features  of  feta  ,  82;  develop- 
ment of  chorionic,  78;  development  of 
placental,  78;  earliest  embryonic,  78; 
fetal,  79;  of  newly  born,  failure  of,  839; 
peculiarities  of  fetal,  82. 

Circulatory  system,  diseases  of,  in  preg- 
nancy, 325-328. 

Cleidotomy,  961;  in  dystocia  from  un- 
usual width  of  shoulders  and  chest,  564. 

Climacteric,  26,  39;  conception  after,  121. 
(See  Menopause.) 

Cliseometry,  179. 

Clitoris,  defects  in,  287;  adhesion  of  hood 
of,  in  newly  born,  796. 

Clothing,  in  pregnancy,  187;  of  newly  born, 
786;   in  prematurity,  803,  805. 

Coccygodynia  from  labor,  615. 

"Coffin  birth,"  669. 


Coitus,  in  pregnancy,  188;  interruptus, 
38;  reservatus,  38;  time  of,  most  favor- 
able for  conception,  27. 

Cold,  in  mastitis,  831,  in  ophthalmia 
neonatorum,  835,  in  puerperal  endo- 
metritis, 753,  754;  in  puerperal  pel- 
vic peritonitis,  755,  in  puerperal  par- 
ametritis, 755;  in  puerperal  perimet- 
ritis, 736;  in  puerperal  salpingitis  and 
oSphoritis,  754,  in  puerperal   infection, 

751- 

Colic,  of  newly  born,  852. 

Colon  irrigation  in  puerperal  infection,  751. 

Colostrum,  description  of,  683. 

Colporrhexis,  595. 

Coma  in  eclampsia,  301. 

Compression,  danger  of  forceps,  989;  in 
treatment  of  cephalhematoma,  831. 

Conception,  27;  after  climacteric,  121;  avoid- 
ance of,  in  pelvic  deformity,  715;  means 
of  preventing,  37,  38;  sequelas  of  pre- 
vention of,  39;  time  favorable  for,  27. 

Condensed  milk,  components  and  reaction 
of,  794- 

Confinement,  calculation  of  date  of,  146,  147. 

Congestion,  of  organs,  in  pregnancy,  130; 
passive,  of  placenta,  228. 

Conjugate  diameter  of  pelvis,  166;  external 
(Baudelocque's),  164;  external  in  preg- 
nancy, 164;  external  and  internal, 
relation  between,  164;    true,  168-171. 

Connective  tissue,  origin  of,   62. 

Constipation,  cause  of  nonseptic  puerperal 
fever,  743;  in  pregnancy,  115,  323, 
treatment  of,  186,  323,  324;  in  puer- 
perium 705,  739,  743;  of  newly  born, 
853;   treatment  of,  743. 

Contracted   pelves.      (See   Pelvic  deformiir.) 

Contraction,  false  uterine,  43 1 ;  intermit- 
tent, in  pregnancy,  123;  uterine,  in 
labor,  429-431;   in  third  stage  of  labor 

439- 

Contraction  ring,  uterine,  402. 

Convulsions,  in  eclampsia,  304;  of  the 
newly  bom,  in  atelectasis,  839,  in  colic, 
852,  in  constipation,  854,  in  septic  in- 
fection, 841. 

Cord,  spinal,  origin  of,  62;  umbilical  (see 
Umbilical  cord). 

Corpus  luteum,  18,  retrograde  changes  in,  19. 

Corsets,  36;  first  use  of,  in  puerperium,  698; 
French,  maternity,  in  pregnancy,    194. 

Coryza  neonatorum,  septic,  843. 

Cotyledons,  placental,  71. 

Cough,  nervous  and  spasmodic,  in  preg- 
nancy, 331. 

Counter-irritation,  in  puerperal  neuritis, 
770. 

Cow'smilk,  and  human,  compared,  789;  com- 
position of,   789. 

Coxalgic  pelvis,  649. 

Coxitis,  649. 

Cramps,  in  pregnancy,  114. 

Cranial  bones,  injuries  of,  at  birth,  828. 

Cranioclasis,  947-951;  in  pelvic  deform- 
ity, 663;    substitutes  for,  955. 

Craniotabes,  268. 

Craniotomy,  955;  in  dead  fetus,  930;  in 
interlocking  of  fetal  heads,  658;  in  ky- 
phosis, 646;  in  obstructed  labor  due  to 
levator  ani,  612;  in  threatened  rupture 
of  uterus,  590. 


INDEX. 


1051 


Cranium,  changes  in  cavity  of,  in  preg- 
nancy, 1 1 8. 

Cravings  in  pregnancy,  115. 

Crede's,  method  of  placental  expression, 
491,  method  with  eyes  of  newly  born, 
835,  ointment  in  puerperal  infection, 
751,  silver  in  endometritis,  754. 

Creolin,  its  use  in  obstetrics,  753,  882. 

Crochet,  loio. 

Curettage,  103 1;  choice  of  instruments  for, 
1031;  digital,  1031;  in  abortion,  35 9- 
361;  in  puerperal  infection,  756;  effects 
of.  7531  objections  to,  756. 

Cutaneous  sepsis  of  newly  born,  844. 

Cyanosis,  in  atelectasis  of  newly  born, 
839;  in  failure  of  circulation  in  newly 
born,  839;  in  prematurity,  802;  in 
puerperal  thrombosis  and  embolism, 
768;    of  newly  born,  816. 

Cystic  degeneration  of  chorion,  198. 

Cystic  tumor  of  broad  ligament,  diagnosis 
of,  from  hydramnios,  206. 

Cystitis,  in  pregnancy,  317;  in  puerperium, 
707,  727;    septic,  treatment  of,  754. 

Cystocele,  cause  of  dystocia,  614;  in  preg- 
nancy, 318. 

Cysts,  fetal,  270;  of  umbilical  cord,  240; 
ovarian,  diagnosis  of,  from  hydramnios, 
206;  pelvic,  638;  placental,  235;  sub- 
lingual,  in   newly   born,    852;     vaginal. 


D. 

Deafness  in  pregnancy,  335. 

Death,  from  prolonged  labor  in  case  of  can- 
cerous uterus,  610;  maternal,  effect  of, 
on  fetus,  670;  of  fetus,  272;  sudden,  in 
labor  669,  in  pregnancy,  369,  in  puer- 
perium, 773-776. 

Decapitation,  955-960;  extraction  after, 
960. 

Decidua,  apoplexy  of,  195;  atrophy  of, 
196;  changes  in,  in  puerperium, 
682;  development  of ,  48 ;  disappearance 
of,  48;  disease  of,  1 91-198;  fatty  de- 
generation of,  49 ;  graviditatis,  45 ;  re- 
flexa,  45,  66;  in  twin  pregnancy,  142; 
serotina,  45;  vera,  45,  66. 

Deformities,  fetal,  classifications  of,  244; 
fetal,  producing  dystocia,  660;  of 
genital  organs,  clinical  significance  of, 
287;  recurrent,  266,  267;  pelvic,  diag- 
nosis of,  by  Rontgen  pelvimetry,  177. 

Delirium  in  labor,  668;  in  puerperal  infec- 
tion, 748. 

Delivery,  calculating  date  of,  146,  687; 
different  signs  of,  in  primiparas  and 
multiparas,  688;  feigned,  449;  forcible, 
964;  immediate,  in  asphyxia  neon- 
atorum, 817;  impregnation  subse- 
quent to,  689;  of  placenta  and  mem- 
branes, 1025-1031;  operations  for,  963- 
1031;  post-mortem,  669;  premature 
indication  for,  890;  signs  of  recent, 
687;  treatment  of  mother  after,  688; 
unconscious,  449. 

Dermatitis  exfoliativa  neonatorum,  844. 

Dermoid  cysts,  cause  of  dystocia,  605;  of 
newly  born,  852;    of  umbilicus,  242. 

Deutoplasm  of  ovum,  42. 

Diabetes,    an   indication   for   prevention   of 


reproduction,  38;  effect  of  maternal, 
on  newly  born,  262;  in  pregnancy, 
262,  320. 

Diagonal  conjugate  diameter,  168. 

Diameters  of  pelvis,  168,  380,  381,  384. 

Diaphragm,  action  of,  in  labor,  428;  forma- 
tion of,    60. 

Diarrhea,  in  newly  born,  853,  841;  in  preg- 
nancy,  115,  324. 

Diastasis,  of  abdominal  muscles,  711;  of 
long  bones  at  birth,  829;  of  pelvic 
joints,  cause  of  dystocia,  615. 

Diet,  effect  of  mother's,  on  milk,  685 ; 
improper,  a  cause  of  subinvolution,  186; 
in  diarrhea  of  newly  born,  853;  in  pel- 
vic deformity,  651;  in  pregnancy,  186; 
in  puerperium,  693 ;  in  threatened 
eclampsia,  309. 

Digestion,  and  assimilation  of  newly  born, 
failure  of,  840;  in  newly  born,  782; 
in  puerperium,  676. 

Digestive  disturbances,  cause  of  dystocia, 
669. 

Digestive  tract,  changes    in,  in  pregnancy, 

"5- 

Dilatation,  of  cervix,  in  labor,  435,  mstru- 
mental,  902-906,  manual,  895-902,  of 
vagina  and  vulva,  906. 

Diphtheria,  bacterial  toxemia  of,  740;  in 
puerperium,  737,  740. 

Diseases,  antenatal,  807-812;  due  to  bac- 
teria and  fungi,  in  newly  born,  840-847; 
general,  in  puerperium,  773;  inci- 
dent to  change  of  environment  in  newly 
born,  837-840;  of  unknown  nature  of 
newly  born,  847-851. 

Disinfection,  of  hands,  1 51-153;  of  field  of 
operation,  860. 

Dislocations,  fetal,  270. 

Displacements,  after  interrupted  pregnancy. 

356. 

Diuretics  for  newly  born,  856. 

Double  uterus,    283,   367. 

Douche,  vaginal,  881. 

D'Outrepont's  method  of  version,  924. 

Dress,  hygienic,  36. 

Drink  in  pregnancy,   186. 

Droysen's  weights  of  embryo  and  fetus,  86.  87. 

Dry  labor,  570. 

Duct,  of  Arantius,  81;  right,  of  Cuvier,  81; 
Mullerian,  formation  of,  60;  Wolffian, 
formation  of,  60. 

Ductus  arteriosus,  81,  82,  closure  of,  780; 
venosus   78,  81,  82 

Dystocia,  fetal,  from  faulty  attitude,  499" 
527,  from  faulty  position,  545-555.  from 
faultv  presentation,  527-545,  from  gen- 
eral fetal  conditions,  555-566;  maternal, 
from  the  forces,  567-574,  from  general 
maternal  conditions,  665-671,  from  ob- 
structed labor,  602-665,  in  parturient 
tract  and  adnexa,  574-602, 

Dysuria,  due  to  urinary  retention,  318;  in 
pregnancy,  317.  . 

E. 

Ear,  external,  formation  of,  56;  origin  of, 
62. 

Eclampsia,  964;  albuminuria  in,  307;  al- 
buminuria absent  in,  309;  aura  in,  305; 
bimanual  dilatation  in,   900;    bleeding 


1052 


INDEX. 


in,  312;  blindness  in,  305;  Caesa- 
rean  section  in,  1012;  cause  of  sudden 
death  in  pregnancy,  369;  control  of 
convulsions  in,  311;  curative  treatment 
of,  310-315;  definition  of,  304;  diagno- 
sis of,  307,  from  apoplexy,  307,  from 
epilepsy,  307,  from  hysteria,  307,  from 
meningitis,  307;  diet  in  threatened, 
309;  drugs  in  (see  Treatment);  effect  of, 
on  fetus  and  labor,  306,  on  newly  born, 
809;  elimination  of  posions  presumed 
to  cause  convulsions  in,  311,  emptying 
of  uterus  in,  312;  etiology  of,  304; 
frequency  of,  304;  in  primiparas,  314, 
665;  internal  podalic  version  in,  929; 
operative  treatment  of,  312-314;  path- 
ology of,  304;  preventive  treatment  of, 
308-310;  prodromal  period  of,  305; 
prognosis  of,  307;  saline  solution  in- 
jections in,  861;  stage  of  coma  in, 
306;  stage  of  invasion  in,  305;  sympto- 
matology of,  305;  and  acute  toxe- 
mia of  pregnancy,  differences  between, 
296;  treatment  of,  308-315;  urine  m, 
307;  vaginal  Caesarean  section  in,  1024; 
venesection   in,    312. 

Ecthyma  neonatorum,  845. 

Ectoderm,  53,  55,  58,  61,  64 

Ectopic  gestation,  361-366;  celiotomy  in, 
1025;  diagnosis  of,  365;  etiology  of,  362; 
laparotomy  in,  366;  pathology  of,  362; 
symptoms  of,  363-365;  treatment  of, 
365,366;    varieties  of,  361. 

Eczema,  in  pregnancy,   291,  337. 

Edgar's,  irrigating  tube,  884,  method  of  en- 
gaging fetal  head,   184. 

Education  in  relation  to  sexual  functions,  ^6 

Elbow  and  knee  presentation,  differential 
diagnosis  of   536. 

Electricity,  in  galactorrhea,  761 ;  in  paralysis 
of  arm,  827;  in  paralysis,  traumatic, 
771;  in  subinvolution,  709. 

Elephantiasis,  congenital,  808;  general  cys- 
tic, 268. 

Ellipse,  fetal,  420,  443. 

Emanuel's  disease,  231. 

Embolism,  air,  in  puerperium,  776;  puer- 
peral, 768;  pulmonary,  cause  of  sud- 
den death  in  puerperium,  775. 

Embryo,  anatomy  of,  53-66;  arrested  de- 
velopment of,  243;  characteristics  of,  in 
different  lunar  months,  83-88;  nutrition 
of,  78;  pathology  of  early  human,  242; 
vitelline  circulation  of,  78. 

Embryotomy,  942,  943;  in  cancer  of  uter- 
us, 610;  in  face  presentation,  518;  in 
over-developed  fetus,  562;  in  pelvic  de- 
formity 658,  659,  660;  in  persistent 
mento-posterior  positions,  552;  in 
threatened  rupture  of  uterus,  589; 
indications  for,  10 12. 

Emotion,  in  etiology  of  accidental  hemor- 
rhage, 226;  a  cause  of  fever  in  puer- 
perium, .745;  in  relation  to  menstrua- 
tion, 23,  24,  120,  121. 

Emphysema  in  pregnancy,   329. 

Encephalocele,  of  fetus,  265,  cause  of  dys- 
tocia, 563. 

Endocarditis,  in  pregnancy,  325;  of  fetus, 
263,  875;    puerperal,  806. 

Endometritis,  a  cause  of  interrupted  preg- 
nancy, 3  49 ;  cervical,  a  cause  of  ante-par- 


tum  hemorrhage,  371 ;  chronic,  a  cause  of 
fetal  death,  270;  catarrhal,  192;  de- 
ciduae  cystica,  195;  due  to  mixed  in- 
fection, in  puerperium,  724-726;  in 
etiology  of  accidental  hemorrhage,  226; 
puerperal,  718-724;  puerperal,  infec- 
tious, 722;  puerperal,  malignant,  733, 
730;  puerperal,  results  of,  714;  puer- 
peral, saprophytic,  719-721;  puerperal, 
varieties  of,  718;    puerperal,  treatment 

of,  753- 

Endometrium,  changes  in,  during  menstru- 
ation, 21. 

Enema,  ante-partum,  472. 

Engagement  of  head  in  vertex  presentation, 

441,453,457- 

Enteroclysis,  863. 

Entoderm,  53,  54,  62. 

Epidermis,  55;   origin  of,  63. 

Epilepsy,  diagnosis  of,  from  eclampsia,  307; 
due  to  cerebral  hemorrhage  in  labor, 
824;  indication  for  prevention  of  re- 
production, 38;  in  pregnancy,  335. 

Episiotomy,  910;  in  dystocia  due  to  cedema, 
613. 

Epithelium,  origin  of,  61. 

Ergot,  after  abortion,  361;  after  labor, 
493;  cause  of  rupture  of  uterus,  585; 
in  accidental  hemorrhage,  228;  in  hem- 
orrhages of  newly  born,  850 ;  in  puerperal 
endometritis,  753;  in  puerperal  hemor- 
rhage, 704;  in  puerperal  septic  phlebi- 
tis, 736;  in  puerperal  infection,  817; 
in  puerperium,  679;  in  subinvolution, 

709-  .     , 

Erosions,    cervical,    cause    of    ante-partum 

hemorrhage,  372. 
Eruptions,  in  septic  infection  in  puerperium, 

773- 

Erysipelas  of  fetus,  256;  of  newly  born, 
846;  in  pregnancy,  256,  336;  m  puer- 
perium, 739. 

Erythema,  puerperal  septic,  740. 

Ether,  administration  of,  867;  and  chloro- 
form, choice  between,  in  labor,  865, 
868;  in  obstetric  operations,  867,  868; 
in  first  stage  of  labor,  572;  in  labor, 
480,  482;  in  labor,  fetal  asphyxia 
from,  261;  in  manual  extraction  of 
placenta,  1029. 

Eustachian  valve,  81,  82. 

Evisceration,  960. 

Evolution,  spontaneous,  in  shoulder  pres- 
entation, 541. 

Examination,  methods  of,  in  diagnosis  of 
pregnancy,  123;  limitation  of  inter- 
nal, in  obstetrics,   953. 

Excitement,  emotional,  cause  of  fever  in 
puerperium,  974;  effect  of,  on  men- 
struation, 24;  to  be  avoided  in  preg- 
nancy, 188. 

Exercise,  in  pregnancy,  185;  in  puerperium, 
697;   in  threatened  eclampsia,  309. 

Exophthalmic  goitre  in  pregnancy,  328. 

Expression  of  fetus,  537,  963. 

Extension  of  fetal  head,    412,  455,  457. 

Extrauterine  pregnancy.  (See  Ectopic  ges- 
tation.) 

Extremities,  changes  in  lower,  in  preg- 
nancy, 114. 

Exudations,  pelvic,  diagnosis  of,  from  preg- 
nancy, 135. 


INDEX. 


1053 


Eyes,  formation  of,  56;  of  newly  born  child, 
cleansing  of,  485;  loss  of,  from  purulent 
ophthalmia,  833. 


F. 

Face  presentation,  508-518;  and  breech  pres- 
entation, differential  diagnosis  of,  536; 
diagnosis  of,  514;  embryotomy  in, 
518;  forceps  in,  518;  manual  correc- 
tion of,  91 1-9 1 4;  mechanism  of,  510, 
511;  perforation  in,  946;  treatment  of, 
518;  version  in,  527,  528. 

Fallopian  tubes,  ciliary  current  in,  18; 
hgation  of,  in  Caesarean  section,  1015; 
obliteration  of,  for  prevention  of  con- 
ception, 39;  origin  of,  61;  pregnancy 
in,  361. 

Fats,  regulation  of,  in  modified  milk,  789, 
790. 

Fatty  degeneration  of  newly  born,  851; 
of  heart  in  pregnancy,  326;  of  placenta, 
236. 

Feces,  of  newly  born,  781. 

Fecundation,  27. 

Feeding,  artificial,  786-794;  infant,  proper 
intervals  for,  787. 

Feet,  extraction  by,  in  breech  presentation. 

973-       . 

Feigned  delivery,  449. 

Female  pronucleus,  42. 

Feticide,  39,  344;    therapeutic,  39. 

Fetus,  408;  acute  poisoning  of,  261;  ante- 
natal diseases  of,  255-272;  atelectasis 
in,  779;  attitude  of,  420;  bladder  disten- 
tion of,  267;  blood,  circulation  of,  in, 
79-82;  blood  of,  79;  bone  disease  of, 
268;  bones,  cranial,  of,  410;  calcifica- 
tion of.  274;  cardiac  lesions  in,  263;  cere- 
brospinal meningitis  of,  258;  death  of, 
272-274;  deformities  and  monstrosities 
of,  classification  of,  244;  delivery  of, 
in  Cesarean  section,  10 14;  develop- 
ment of,  in  different  months  of  gestation, 
84-88;  diameters  of  head  of,  414-416; 
diseases  of,  262-269;  embryotomy  upon 
dead,  943,  upon  living,  944;  excretions 
of,  67,  79;  expression  of,  963;  extrac- 
tion of,  in  low  forceps  operation,  993; 
fontanelles  of,  411;  head  of,  408-417; 
heart  sounds  of,  127,  463;  hereditary 
predispositions  of,  266;  maternal  in- 
fluence on,  188;  measurements  of, 
414-422;  over-size  of,  561;  posture  of, 
420;  traumatisms  of,  269;  trunk 
measurements  of,  417;  viability  of,  after 
death  of  mother,  670;  vitality  of,  in 
different  months,  85;  weight  of,  in 
different  months,   86,   87. 

Fever,  due  to  constipation,  743;  due  to 
intercurrent  and  complicating  disease 
in  puerperium,  737;  due  to  reflex 
irritation,  744,  750;  inanition,  840;  in 
convulsions  of  newly  born,  855;  in 
neurotic  conditions,  in  puerperium,  743, 
745,  treatment  of,  751;  in  pregnancy, 
371;  in  puerperal  infection,  747,  748; 
in  septic  infection  of  newly  born,  841; 
in  tetanus  of  newly  born,  846 ;  maternal, 
effect  of,  on  fetus,  271 ;  non-septic,  743- 
747;  pseudo  in  puerperium,  743; 
puerperal,   classification   of,   712,    puer- 


peral, defined  by  Semmelweis,  148;  in 
puerperal  phlebitis,  736;  in  pyemia, 
741;  in  sapremia  738;  in  septicemia, 
741;  "one-day,"  719,  748;  in  retro-dis- 
placements, of  puerperal  uterus,  744; 
resorption,  748;  in  rupture  of  the  uter- 
us, 744,  true  puerperal,  746. 

Fibrin,  increase  of,  in  blood,  m  pregnancy, 
117. 

Fibroids,  cause  of  intra-partum  hemorrhage, 
671 ;  in  pregnancy,  282. 

Fibroma,  diagnosis  of,  from  pregnancy,  134; 
fetal,  270;  of  virgin  uterus,  37;  pelvic, 
638. 

Fibrous  tissues,  changes  of,  in  pregnant 
uterus,  105. 

Fillet,  915;  as  tractor,  1007;  in  breech 
extraction,  971 ;  soft,  1007-1009. 

Finger-nails,  care  of  surgeon's,  150. 

Fistula,  vaginal,  diagnosis  of,  1032;  vesical 
and  rectal,  repair  of,  1032. 

Fixation  abscess  in  puerperal  infection,  752. 

Flat  pelvis,  63 1 ;  induction  of  premature 
labor  in,  890. 

Flat  rachitic  pelvis,  631. 

Flatulence  in  pregnancy,  115. 

Flesh  moles,  345. 

Flexion,  412;  incomplete,  412,  500-503;  in 
vertex  presentation,  451,  457,  460;  of 
head  in  breech,  531;  in  brow,  508;  in 
face   presentation,    513. 

Flooding,  577.  (See  Post-partum  hemor- 
rhage.) 

Follicles,  arrangement  of,  in  ovary,  42; 
sebaceous,  in  pregnancy,  89. 

Fontanelles,  false,  412;  fetal,  411;  of  newly 
born,  785. 

Food,  in  prematurity,  803;  in  puerperal 
infection,  751;  in  relation  to  sexual 
functions,  36. 

Foods,  patented  or  proprietary,  for  newly 
born,  794. 

Foot  and  hand,  differential  diagnosis  of,  in 
pelvic  presentation,  536. 

Foot  and  shoulder  traction  in  breech  pres- 
entation, 979. 

Foramen,  ischio-pubic,  379;    ovale,  81. 

Forceps,  983-1007;  action  of,  989;  antero- 
posterior, 984;  application  of,  cephalic, 
990-992,  pelvic,  992;  as  rotators, 
1002;  axis-traction,  998;  in  high  opera- 
tion, 997,  Breus's,  984;  cause  of  rup- 
ture of  vagina,  594;  Chamberlen's,  983; 
classification  of,  990;  delivery,  posture 
in,  879;  description  of,  9S3;  Elliott's, 
984;  facial  paralysis  due  to,  824;  high, 
990,  997;  in  pelvic  deformity,  657;  his- 
torical, 983;  in  after-coming  head,  979, 
1003-1005;  in  asphyxia  neonatorum, 
817;  in  breech  extraction,  973  ;  inbreech 
presentation,  538;  in  brow  presen- 
tation, 508,  1006;  in  cancer  of  uterus, 
610;  in  congenital  hydrocephalus,  563; 
in  deep  transverse  head,  1006;  in  de- 
layed labor,  573;  in  dorsal  displace- 
ment of  arm,  521;  in  dystocia  due  to 
affections  of  fetal  trunk,  564  in  eclamp- 
sia, 314;  in  elderly  primiparag,  666;  in 
face  presentation.  518,  1005,  1006;  in 
funnel-shaped  pelves,  626;  in  interlock- 
ing of  fetal  heads,  558;  in  kyphosis, 
646;  in  mento-posterior  positions.  1006; 


1054 


INDEX. 


in  obstructed  labor  due  to  levator  ani, 
612;  in  occipito-posterior  positions, 
999;  in  occlusion  of  external  os,  609; 
in  over-developed  fetus,  562;  in  pelvic 
deformity,  658;  in  pelvic  presentation, 
1003;  in  persistent  mento-posterior 
positions,  552;  in  persistent  occipito- 
posterior  positions,  548;  in  prolapse  of 
arms,  521;  in  prolapse  of  umbilical  cord, 
526;  in  rupture  of  uterus,  589,  590;  in 
scoliosis,  647;  in  short  cord,  559;  in 
transverse  position  of  head  at  pelvic  out- 
let, 554;  in  vaginismus,  610;  indica- 
tions, 985;  low,  990,  992-996;  extrac- 
tion, of  fetus,  993,  994,  general  princi- 
ples of,  994,  median,  990,  996;  Naegele's. 
984;  operations,  frequency  of,  985, 
high,  ordinary  forceps,  997,  axis-traction 
forceps,  998;  preparation  for,  988;  tech- 
nique of,  988;  Penoyee's,  984;  placental 
in  abortion,  360;  prerequisites  and  con- 
traindications for,  987,  prognosis  of,  987; 
Scanzoni's  manoeuvre  with,  1006;  Simp- 
son's, 984;  slipping  of,  988;  Smellie's, 
983,  sterilization  of,  988;  straight, 
984;  Tarnier's,  984. 
Fore-coming    head,    manual    extraction    of, 

965-  .   , 

Formaldehyde  solutions,  intravenous  infu- 
sion of,  in  puerperal  infection,  752. 

Fourchette,  rupture  of,  597;  lacerations, 
repair  of,  1035. 

Fractures,  fetal,  269;  of  cranial  bones  at 
birth,  828 ;  of  facial  bones  at  birth,  829 ; 
of  long  bones  at  birth,  829;  of  pelvis, 
anomalies  due  to,  638. 

Functions  of  pelvic  joints,  379. 

Fundus,  care  of,  in  third  stage  of  labor, 
490;  height  of,  in  puerperium,  681, 
in  different  months  of  pregnancy,  146; 
pressure  on,  in  labor,  488. 

Funis.     (See  Umbilical  Cord.) 


Gait,  change  of,  in  pregnancy,  118 

Galactocele,  768. 

Galactogogues,  685,  760. 

Galactorrhea,  685,  761. 

Ganglia,  nervous,  origin  of,  56,  62. 

Gangrene  in  puerperal  thrombosis  and  em- 
bolism, 768. 

Gangrenous  stomatitis  of  newly  born,  843. 

Gas-bacteriemia,  742;  gas  sepsis,  742. 

Gastro-enteritis  of  newly  born,  844. 

Gastro-intestinal  infection  of  newly  born, 
843,844. 

Genital  organs,  clinical  significance  of  de- 
formities of,  287,  288;  malformations 
of,  in  pregnancy,  282-288 ;  origin  of,  62  ; 
external,  in  pregnancy,  89,  in  puer- 
perium, 677. 

Germ-layers,  formation  of,  5 1 ;  inversion 
of,  64;  organs  and  tissues  derived  from, 
62. 

Gestation,  ectopic,  diagnosis  of,  from  preg- 
nancy, 136;  protracted,  144,  145. 

Gestational,  insanity,  335;  melancholia, 
mania  and  dementia,  332-335;  neu- 
ralgias, 335;   paralyses,  335. 

Giant  pelvis,  627. 

Gingivitis  in  pregnancy,  321. 


Glands,  decidual,  45,  46;  inflammation  of 
Montgomery's,  761 ;  lymphatic,  changes 
of,  in  pregnancy,  116;  mammary, 
origin  of,  62  ;  mucous  vaginal,  in  preg- 
nancy, 89;  pelvic,  400;  salivary,  origin 
of,  62,  84,  in  pregnancy,  322;  sweat,  in 
pregnancy,  117;  thymus,  origin  of, 
62;  uterine,  changes  in,  in  menstrua- 
tion, 21;  uterine,  in  pregnancy,  78; 
vaginal,  89;    vulval,  89. 

Gloves,  rubber,  151;    sterilization  of,  153. 

Glycosuria,  in  pregnancy,  319;  in  puer- 
perium, 320. 

Goitre,  congenital  cystic,  cause  of  dystocia, 
563;  in  pregnancy,  328. 

Gonococcus,  in  puerperal  infection,  149,  in 
ophthalmia  neonatorum,  832-837. 

Gonorrhea,  puerperal,   727,   737. 

Gonorrheal  stomatitis,  837. 

GOttengen's  weights  of  embryo  and  fetus, 
86,87. 

Graafian  follicles,  development  of,  17; 
rupture  of,  17. 

Granuloma,  infectious,  of  placenta,  232,  233. 

H. 

Habitual  death  of  fetus,  891. 

Hand,  choice  of  internal,  in  internal  podalic 
version  in  cephalic  presentation,  93 1 , 
choice  of,  in  internal  podalic  version 
in  shoulder  presentation,  935;  diagnosis 
of,  from  foot,  536,  933 ;  disinfection,  151- 
153 ;    origin  of,  61. 

Head,  fetal,  408-420;  after-coming  (see 
After-coming  head) ;  changes  in  shape  of, 
according  to  presentation,  502,  504,  512, 
518,  519,  546,  785;  delivery  of,  481-485; 
in  persistent  sacro-posterior  cases,  979, 
980;  detached,  forceps  to,  1005;  en- 
gagement and  descent  of,  in  vertex  pres- 
entation, 451;  excessive  flexion  of,  499; 
fore-coming  (see  Fl re-coming  head);  m 
complete  flexion  of,  500-503;  inter- 
locking, 614;  manual  engagement  of, 
1 83 ;  oversize  of ,  5  -  2 ;  in  brow  presenta- 
tion, 508;  rotation  of,  in  breech  cases, 
447;  transverse  position  of,  at  pelvic 
outlet,  553,  554. 

Heart,  beginning  of  function  of,  84;  changes 
in,  in  pregnancy,  115,  116;  develop- 
ment of,  79,  81;  disease  of,  indication 
for  prevention  of  reproduction,  38, 
dystocia  due  to,  668;  failure,  posture 
in,  treatment  of,  in  labor,  878;  fetal,  81; 
location  of,  161;  hypertrophy  of,  in 
pregnancy,  115,  in  puerperium,  677; 
murmur,  in  puerperium,  674;  muscle, 
affections  of,  in  pregnancy,  326;  of 
newly   born,    783;    rate  of  fetal,  128. 

"Heat"  and  menstruation,  relation  be- 
tween,  23. 

Hegar's,  dilator,  903  ;  sign,  in  pregnancy,  123. 

Hematocele,  extrauterine  and  extraperito- 
neal, 585;  in  pregnancy,  327;  origin 
of>  327,  364;  pelvic,  364;  diagnosis 
of,  from  pregnancy,  137. 

Hematoma,  cause  of  dystocia,  613;  of 
broad  ligament,  366;  of  placenta, 
229-231;  of  sternomastoid,  832;  of 
umbilical  cord,  241;  of  vagina  and 
vulva,   291,  613,   704. 


INDEX. 


1055 


Hematometra,  diagnosis  of,  from  pregnancy, 
132. 

Hematosalpinx,  origin  of,  364. 

Hematuria,  in  newly  born,  850;  in  preg- 
nancy,   319;     in   puerperium,    705. 

Hemiopia,   in   puerperium,    771. 

Hemiplegia  and  aphasia,   puerperal,   771. 

Hemoglobin  of  newly  born,  783. 

Hemoglobinuria  in   Winckel's  disease,   851. 

Hemorrhage,  accidental,  224-228;  after 
abortion,  354,  355;  ante-partum,  causes 
of,  371,  372;  cause  of,  in  placenta 
praevia,  215;  cerebral,  of  newly  born, 
823;  concealed,  224;  in  premature 
detachment  of  normally  situated  pla- 
centa, 225;  control  of,  in  third  stage 
of  labor,  439;  in  Ceesarean  section,  1014; 
curettage  in,  358,  359;  from  genitals 
in  female  infants,  850;  from  umbil- 
ical cord,  241;  in  abortion,  354; 
in  atony  of  uterus,  360;  in  congen- 
ital syphilis,  809;  in  general,  of  newly 
born,  848-850;  in  hydatidiform  mole, 
200;  in  inversion  of  uterus,  591; 
in  paralysis  of  placental  site,  580; 
in  placental  polypi,  237;  in  hemor- 
rhoids in  pregnancy,  324;  in  pre- 
mature labor,  354;  in  puerperal  anemia, 
768;  in  retained  placenta,  574;  in  rup- 
ture of  fetal  cyst,  366;  in  septic  infec- 
tion of  newly  born,  841;  in  twin  labor, 
556;  interstitial,  of  placenta,  229-232; 
partum  or  intrapartum,  671;  patho- 
logical, and  menstruation,  confu- 
sion of,  121;  periovular,  345;  post- 
partum, 556,  577-584;  posture  in, 
878;  puerperal,  701-705;  treatment 
of,  228,  229,  581-584,  861-865;  sec- 
ondary, 701;  in  atony  of  uterus,  579; 
in  retained  placenta,  574. 

Hemorrhoids,  in  pregnancy,  324;  vesical, 
in  pregnancy,  318. 

Hepatic  lesions  and  eclampsia,  304,  305; 
and    the    toxemia    of    pregnancy,    292. 

Hernia,  cause  of  dystocia,  605 ;  in  preg- 
nancy, 118;  of  umbilical  cord,  240; 
vaginal,  cause  of  dystocia,  667;  ven- 
tral, and  pregnancy,  coexistence  of, 
138. 

Hernial  protrusion  of  pregnant  uterus,  281. 

Herpes  gestationis,  338. 

Hicks',  method  of  bipolar  podalic  version, 
advantages  of,  925,  sign  of  pregnancy, 
123,  207. 

Hook,  blunt,  10 10;  in  breech  extraction, 
971. 

Hour-glass  contraction  of  uterus,   574. 

Hydatidiform  mole,  198-201. 

Hydrsemia  in  pregnancy,  327. 

Hydramnios,  66,  204-208;  treatment  of, 
208. 

Hydrencephalocele,  265;    cause  of  dystocia, 

563- 

Hydrocephalus,  congenital,  264,  562;  diag- 
nosis of,   562;    treatment  of,   562,   563. 

Hydrometra,  diagnosis  of,  from  pregnancy, 
132. 

Hydronephrosis,   cause  of  dystocia,    564. 

Hydrorrhea,  amniotic,  203;  gravidarum, 
192. 

Hymen,  after  rape,  t,;^;  carunculae  myrti- 
f ormes  of ,  7  3  5  ;  congenital ,  absence  of,  31  ; 


forms  of,  31;  persistent,  cause  of  dys- 
tocia, 612;    sign  of  virginity,  31. 

Hyperemesis  gravidarum,  323. 

Hyperinosis,  in  pregnancy,  117;  in  puer- 
perium,  677. 

Hypertrophy,  congestive,  of  uterus,  diag- 
nosis  of,    from   pregnancy,    134. 

Hypodermoclysis,  864,   865. 

Hypoplasia  uteri,    286. 

Hypospadias,  273. 

Hypothermia,  puerperal,  747. 

Hysterectomy,  in  puerperal  infection,   757, 

758. 
Hysteria,  diagnosis  of,  from  eclampsia,  307; 
in  pregnancy,  335. 

I. 

Ichthyosis  congenita,   267,   268,   809. 

Icterus,  gravidarum,  303  ;  in  septic  infection 
of  newly  born,  841;    neonatorum,  263. 

Idiocy  due  to  fetal  cerebral  hemorrhage  in 
labor,  824. 

Iliacus  muscle,  description  of,  395. 

Impetigo  herpetiformis,  339;  cause  of  sud- 
den death  in  pregnancy,   369. 

Impregnation,  27,  44;  artificial,  29;  rela- 
tion between,  and  menstruation,  28; 
time  most   favorable  for,    29. 

Inanition  fever,   840. 

Inanition  of  newly  born,  840. 

Incarceration    of    pregnant    uterus,    275. 

Incontinence  of  urine,  in  pregnancy,  318: 
in  puerperium,  706;  diagnosis  of,  from 
hydrorrhoea  gravidarum,  193. 

Incubator,  Denucl's,  805 ;  dangers  from,  806 ; 
in  prematurity,  803;  Lion,  805;  proper 
temperature   of,  806;   Tarnier's,  805. 

Indigestion,  gastric  and  intestinal,  in  preg- 
nancy, 115. 

Infant  feeding,  786,  795, 

Infant,  first  care  of,  785;    rape  upon,  35 

Infarcts,  placental,    229,    231,    233,    234. 

Infection,  consecutive,  focal,  puerperal,  727. 
738;  primary,  focal,  718-727;  septic, 
in  interrupted  pregnancy,  355. 

Infectious  diseases,  in  pregnancy,  336,  337. 
of  newly  born,  acute,  808,  809;  chronic, 
809. 

Inflammations,  genital  and  extra-genital, 
in  puerperium,   714. 

Infusion,  saline       (See  Saline  infusion.) 

Injuries,  and  accidents  in  pregnancy,  369, 
370;  from  labor,  repair  of,  103  2-103 7; 
to  cranial  bones  at  birth,  828;  to 
placenta,    224;  to  scalp  at  birth,   830. 

Inlet,  pelvic,  anatomical,  381. 

Insanity,  332-335;  of  labor,  668;  of  lac- 
tation, 772;  of  pregnancy,  332—335; 
of  puerperium,  771-773. 

Intercourse,   sexual,   stages  of.   38. 

Interlocking    of    fetal    heads,    558. 

Internal  cephalic  version,  924. 

Internal  podalic  version,  929-936. 

Intestinal,  anomalies  in  puerperiimi,  705. 
obstruction  of  newly  born,   854. 

Intestines,  topographical  relations  of,  at 
term,  112. 

Inversion  of  uterus,  590. 

Involution,  679-682;  disturbed,  in  puer- 
peral infection,  748;  effect  of  nursinq 
on,    786 


1056 


INDEX. 


Ischio-pubiotomy,    936;     in    Naegele's    pel- 
vis,   626. 


J. 

Jacquemier's  sign  in  pregnancy,  125. 

Jaundice  in  newly  bom,  851;  in  preg- 
nancy, 296. 

Joints,  pelvic,  376-379;  changes  of,  in 
pregnancy,  114. 

Justo-minor  sequabiliter  pelvis,   618. 

K. 

Kidney,  congenital  cystic  degeneration  of, 
cause  of  dystocia,  564;  floating,  cause 
of  dystocia,  605 ;  incarceration  of, 
in  pregnancy,  316;  in  puerperium,  676; 
origin  of,  60;  of  pregnancy,  292; 
tumors  of,  in    pregnancy,  316 

Knee  and  elbow  differential  diagnosis  of. 
1002;    in  pelvic  presentation,  589. 

Knots  in  umbilical  cord,   238 

Kyphoscoliosis,  648. 

Kyphosis,  643-646. 

L. 

Labice  in  pregnancy,  89. 

Labor,  abdominal  binder  after,  496;  acute 
psychosis  during,  668;  after  operations 
involving  genitals,  490,  600-602;  an- 
esthesia in,  865-868,  anesthetics  in, 
480,  482;  fetal  asphyxia  from,  261 ;  anti- 
pyrin  in,  867;  asepsis  in,  465;  asystole 
in,  668;  auxiliary  forces  in,  428,  429; 
bed  in.  471;  bimanual  dilatation  in 
delayed  first  stage  of  898,  899,  caput 
succedaneum  in,  437,  453;  CeiA'ical 
dilatation  in,  404;  cervical  shorten- 
ing in,  433;  chill  after,  440;  chloral 
in,  867;  chloroform  in,  866;  cleans- 
ing of  patient  and  bed  after,  495; 
conduct  of,  first  stage  of.  478,  sec- 
ond stage  of,  479,  third  stage  of, 
490,  491;  Death  during,  669;  deep 
transverse  position  in,  446;  definition 
of,  375;  delirium  of,  668;  dehvery 
of  body  in,  488;  delivery  of  head 
between  uterine  contractions,  480-485 ; 
delivery  of  placenta  and  membranes, 
491;  delivery  of  shoulders,  486;  dila- 
tation of  internal  os,  433;  dry,  570; 
duration  of,  448,  464;  Effect  of  eclamp- 
sia on,  307;  engagement  and  des- 
cent during,  441 ;  entrance  of  air  into 
uterine  sinuses  in,  776;  episiotomy  in, 
910;  ergot  after,  493;  ether  in, 
867;  etiology  of,  431;  examination 
in,  473-478;  examination  of  placenta 
and  membranes  after,  491,  492; 
expelUng  forces  in,  428;  expulsion  of 
first  part  of  fetal  ellipse  in,  446; 
expulsion  of  head  in  normal,  454,  457. 
460;  expulsion  of  second  part  of  fetal 
ellipse  in,  447;  expulsion  of  trunk 
in,  455,  460,  extension  of  head  in 
normal,  454;  external  examination 
in,  474;  Factors  concerned  in,  375; 
false,  and  time  of  its  appearance  in 
ectopic  gestation,  364;  false  contrac- 
tions or  pains  before,  431;    false  pains 


distinguished  from  true,  433;  feigned 
delivery,  449;  fetal  impaction  in, 
459;  first  stage  of,  433-437,  bladder 
and  rectum  in,  478;  care  of  mem- 
branes in,  478,  food  and  drink  during, 
479,  limits  of,  464,  presence  of  physician 
during,  478,  sleep  during,  478,  vaginal 
examination  in,  478,  voluntary  forces 
in,  4  7  8 ;  flexion  of  head  in  vertex  presenta- 
tion, 451,  457;  Head  delivery  in, 
480-485;  head  rotation  in  breech  cases 
during,  447;  hematemesis  in,  669; 
hemorrhage  during  third  stage  of,  439; 
immature  (see  Miscarriage) ;  Inconri- 
plete,  714,  contraction  and  retraction 
in,  714,  drainage  in,  714;  indications 
for  induction  of  premature,  890,  891; 
in  elderly  primiparse,  665 ;  inspection 
and  repair  of  perineum  after,  464,  490; 
Management  of,  463,  first  stage  of,  47S, 
second  stage  of,  479-490,  third  stage 
of,  490—496;  means  for  accelerating 
first  stage  of,  572-574;  mechanism  of, 
440-448,  in  breech  presentation,  529, 
in  brow  presentation,  504,  in  face  pre- 
sentation, 510-514,  in  vertex  presenta- 
tions, 451-461;  metrorrhagia  of,  671; 
missed,  368;  morbid  conditions  result- 
ing   from,     714-716;    morphia    during, 

867,  868;  Obstructed,  567,  due  to  levator 
am,  612;  pains  of,  429-431;  Pathologi- 
cal, 499;  perineal  protection  in,  479- 
488;  pernicious  vomiting  during,  669; 
physiological  chill  in,  440 ;  placental  de- 
livery in,  439;  posture  as  an  aid  in,  876- 
879;  positions  in  vertex  presentation, 
451-461;  position  of  fetal  heart  sounds, 
in  vertex  presentation,  463 ;  position  of 
fetus,  in  vertex  presentation,  463 ;  post- 
partum  douche,    495;   posture  in,   478, 

868,  876;  precipitate,  567,  568;  prepar- 
ations for,  465-473;  premature,  342- 
361,  induction  of,  888-895,  in  pelvic 
deformity,  663,  in  placenta  previa,  222, 
in  pernicious  vomiting,  303;  prevention 
of  too  rapid  advance  of  head  in,  480 ;  pro- 
longed, 566,  653;  pulmonary  embolism 
in,  775;  pulse  in,  431;  response  to 
summons  in,  472;  retention  of  secun- 
dines  after,  492;  rubber  gloves  in,  151; 
rupture  of  membranes  in,  435,  479; 
Second  stage  of,  437;  management 
of  second  stage  of,  479-489;  shoulder 
delivery  in,  456;  show  in,  435;  spinal 
anesthesia  in,  868;  stages  of,  432- 
440;  stage  of  dilatation  in,  435-437; 
strength  of  uterine  contractions  in, 
431;  sudden  death  in,  669;  syncope  in, 
580;  Temperature  during,  431;  third 
stage  of,  439,  management  of,  490-493; 
care  of  patient  after,  493-496;  time  of, 
25;  twin,  mortaUty  of,  148;  Uncon- 
scious delivery  in,  449,  450;  uterine 
contractions  in,  429,  437;  uterine  walls 
during,  404,  405 ;  Vaginal  examination 
during,  476-478;  vertex  presentation, 
diagnosis  of,  after  labor,  462,  during 
labor,  461,  462,  prognosis  of,  462;  Wal- 
cher's  position  during,  876;  without 
internal  examination,  477. 

Laborde's  method,  of  artificial  respiration, 
822;    of  tongue  traction,  819,  822. 


INDEX. 


1057 


Lacerations,    of   cervix,    vagina   and    pelvic 

floor,  592-600;    repair  of,  1032-1037. 
Lactation,  insanity  of,  772;   pregnancy  dur- 
ing,   121;    in  relation  to  psychoses  of 
pregnancy,     334;      menstruation     sup- 
pressed during,  24. 

Lanugo,  development  of,  85. 

Laparotomy  in  ectopic  gestation,  366;  in 
intestinal  obstruction  of  newly  born, 
855;  in  ovarian  tumor  in  pregnancy, 
604;  in  puerperal  infection,  757;  in 
puerperal  malignant  peritonitis,  755; 
in  rupture  of  uterus,  590;  in  shoulder 
presentation,  544. 

Larynx,  acute  obstruction  of,  a  cause  of 
labor,  668. 

Latero-flexion   during   pregnancy,    278. 

Latero-prone  posture,  exaggerated,  indica- 
tions for,  873. 

Latero-version  during  pregnancy,   278. 

Lead-poisoning,  effect  of,  on  newly  born,  809. 

Lens,  crystalline,  origin  of,  61 ;  optic,  forma- 
tion of,  62. 

Leucocytosis  in  pregnancy,   117. 

Leucorrhea,  in  pregnancy,  187,  288;  treat- 
ment of,  187. 

Leukemia,    effect   of,    on   fetus,    263. 

Levator  ani  muscle,  cause  of  obstructed 
labor,  612;  description  of,  396;  func- 
tions of,  397. 

Ligaments,  pelvic,  376,  398;  changes  of,  in 
pregnancy,  114;  uterine,  286;  changes 
of,  in  pregnancy,    109. 

"Lightening"  before  labor,  102. 

Limbs,  development  of,  54,  58;  lower, 
changes  in,  in  pregnancy,  114;  of 
fetus,    fractures   of,    at   birth,    829. 

Lineag   albicantiae,    in   pregnancy     117. 

Liquor  amnii,    66;    anomalies  of,    204. 

Lithopedion,  274. 

Live  birth,   448. 

Liver,  acute  yellow  atrophy  of,  and  preg- 
nancy, relation  between,  292;  displaced 
and  pregnancy,  coexistence  of,  136; 
fetal,  part  taken  by,  in  circulation,  81; 
formation  of,  58;  in  fetal  syphilis,  259; 
in  pregnancy,  116;  of  newly  born,  783; 
lesions  of,  in  toxemia  of  pregnancy,  292; 
origin  of,   62. 

Lochia,  alba,  678;  in  puerperium,  678,  679; 
examination  of,  75;  in  puerperal  infec- 
tion, 748;  rubra,  678;  serosa,  678;  vari- 
ation of,  in  different  patients,  701. 

Longings  in  pregnancy,  323. 

Lordosis  pelvis,  649. 

Lungs,  formation  of,  58,  62;  in  fetal  syphilis, 
260;    in  pregnancy,  116,  668. 

Lymphangiomata,  fetal,  270. 

Lymphangitis,  mammary,  during  puer- 
perium, 762. 

Lymphatics,  changes  of  uterine,  in  preg- 
nancy,  108;    pelvic,  400. 

Lysol,  151;  in  endometritis,  726;  in  vaginal 
and  intrauterine  injections,   883. 

M. 

Maceration  of  fetus,  273. 

Malacia,  in  pregnancy,  323 

Malaria,  in  fetus,  257;    in  newly  born,  808; 

in  pregnancy,  257,  337. 
Male  pronucleus,  43. 
67 


Malformations  and  monstrosities  of  newly 
born,  807. 

Malformations,  fetal,  in  plastic  exudation 
of  amnion,  202;  producing  dystocia, 
.560-565. 

Malignant  disease,  after  abortion,  356;  of 
vagina,  cause  of  ante-partum  hemor- 
rhage, 372. 

Mammae,  absence  of,  759;  changes  in,  in 
pregnancy,  114,  115,  126;   hypertrophy 

of,  759- 

Mammary,  abscess  in  newly  born,  851,  irri- 
tation, a  cause  of  fever  during  the  puer- 
perium, 744,  lymphangitis  in  puerpe- 
rium, 762-768. 

Mania  in  pregnancy,  116;  in  puerperium, 
772. 

Manual,  dilatation  of  cervix,  895,  896;  ex- 
traction of  placenta,   1029. 

Marasmus  of  newly  born,  840. 

Marginal  insertion,  of  cord,  237;  of  pla- 
centa prasvia,   213. 

Marriage  as  related,  to  heart  disease,  668', 
to  pelvic  deformity,  656,  to  pelvic 
disease,  37,  38. 

Massage,  in  agalactia,  760;  in  caked  breasts, 
761;  in  constipation  of  newly  born, 
854;  in  galactocele,  868;  in  infantile 
cachexia,  856;  in  mastitis,  765;  in 
paralysis  of  arm,  828;  in  puerperal 
neuritis,  770;  in  puerperium,  697;  in 
traumatic  paralysis,  771;  of  nipples, 
761;  of  uterus  in  subinvolution,   708. 

Mastitis,  762-768;  in  newly  born,  851; 
parenchymatous,  763;  treatment,  765. 
766. 

Maternal  impressions,  266. 

Maturity,  of  fetus,  signs  of,  88;   of  ovum,  42. 

Measles,  in  fetus,  256;  in  newly  born,  808, 
in  pregnancy,  191,  256,  336. 

Mechanism  of  labor,  440-448;  in  breech 
presentation,  529;  in  bregma  presenta- 
tion, 501;  in  brow  presentation,  504; 
in  pelvic  deformity,  616-665  ;  in  coxitis, 
650;  in  deep  transverse  position,  553;  in 
face  presentation,  510;  in  generally  con- 
tracted, nonrachitic  pelvis,  619;  in  Nae- 
gele's  pelvis,  623;  in  occipito-posterior 
presentation,  545;  in  pelvic  presentation, 
529;  in  persistent  mento-posterior 
position,  551;  in  persistent  occipito- 
posterior  position,  545;  in  scoliosis 
706;  in  shoulder  presentation,  540; 
in  simple  flat,  non-rachitic  pelves 
620,  621;  in  simple  flat  pelves,  553; 
in  vertex  presentation,  451. 

Mechanism,  of  post-partum  hemorrhage, 
578;  of  traumatisms  of  the  pelvic  floor, 
599- 

Meconium,  first  appearance  of,  85;   of  newly 
born,    781;     pathological   discharge  of, 
70. 
Medullary,  folds,  55,  56;  cords,  56;  grooves, 

56;    ridges,  56;    plate,  55. 
Melancholia,    in    pregnancy,     116;     melan- 
cholia,   mania,    and    dementia,    gesta- 
tional, 332-337;  the  element  of  sepsis  in, 
334- 
Melena,   or  gastro-intestinal  hemorrhage  of 

newly  born,  840. 
Membranes,   anomalies  of,   cause  of  dysto- 
cia,   605;     artificial    rupture    of,      479 


1058 


INDEX. 


S87,  888,  894,  indications  for,  887, 
technique  of,  888;  at  term,  65;  defi- 
nition of,  63;  delivery  of,  490,  491, 
1025-1031;  dystocia  from  adherent, 
605;  examination  of,  491,  492;  obtur- 
ator, 398;  origin  of,  63;  retention  of, 
5  7  4~5  7  7  '  rupture  of,  in  Caesarean  sec- 
tion, 10 14;  in  labor,  435;  synovial, 
pelvic,  changes  in,  in  pregnancy,  114; 
treatment  of  intact,  in  internal  podalic 
version,  932,  933,  in  shoulder  pres- 
entation, 935. 

Meningitis,  cerebrospinal,  of  fetus,  258; 
diagnosis  of,  from  eclampsia,  307;  in 
abor,    668. 

Meningocele,   265,  831. 

Menopause,    25,    41. 

Menorrhagia  from  natural  defects,  24;  in 
incarceration  of  uterus,  277. 

Menses,  20;  retained,  from  natural  defects, 
24;    suppression  of,  in  pregnancy,  120. 

Menstrual  blood,  characteristics  of,  24; 
prejudice  as  to  deleterious  effects  of, 
24. 

Menstrual  cycle,  23. 

Menstruation,  20 ;  abnormal,  in  subinvolu- 
tion, 133,  134;  age  for  establishment 
of,  21;  and  impregnation,  relation 
between,  28,  29;  and  ovulation,  rela- 
tion between,  25;  and  pathological 
hemorrhages,  confusion  between,  121; 
anomalies  of,  24;  cessation  of,  as  sign 
of  pregnancy,  120;  in  acute  affections, 
conditions  leading  to,  120,  121;  changes 
in  endometrium  during,  21;  conditions 
influencing,  21,  22;  definition,  20;  dis- 
regard of,  dangers  from,  36;  duration 
of,  20;  in  infants,  850;  in  the  obese, 
134;  in  pregnancy,  121;  persistence  of, 
cause  of  ante-partum  hemorrhage,  371; 
phenomena  of,  20,  21;  precocious,  22, 
850;  profuse,  in  uterine  tumors,  134; 
prolonged,  26;    vicarious,   25. 

Mensuration    in    pelvic    deformity,    656. 

Mercurialism,  effect  of,  on  fetus,  262;  in 
pregnancy,    262. 

Mercuric  bichloride,  as  antiseptic,  151; 
ffect    of,    on    spermatozoa,    28. 

Mesoderm,  53;    tissues  derived  from,  6t. 

Metastases,  in  deciduoma  malignum,  198; 
puerperal,  738;   in  septicemia,  741. 

Meteorism  in  malignant  peritonitis,  755;  in 
sapremia,   739. 

Metritis,  chronic,  cause  of  fetal  death,  270; 
diagnosis  of,  from  pregnancy,  133;  in 
pregnancy,  281,  282;  puerperal,  728, 
729. 

Metrophlebitis,  puerperal,  736,  737. 

Metrorrhagia,  following  coitus  interruptus, 
39;  in  deciduoma  malignum,  196;  of 
labor,  671;  of  pregnancy,  371,  372; 
puerperal,  701. 

Milk,  breast,  characteristics  of,  684-686,  789; 
causes  of  poor,  788;  changes  in,  dur- 
ing puerperium,  783-786;  cows',  789; 
comparative  average  .composition  of 
human  and  cows',  789;  composition 
of  average  normal  htiman,  788;  con- 
densed, components  and  reaction  of, 
794;  deficient  secretion  of,  760;  effect 
of  diet  on,  685,  788;  establishment  of 
secretion   of,    787;     excessive   secretion 


of,  760,  761;  formulae  for  a  home 
modification  of,  791;  general  direc- 
tions for  the  modification  and  sterili- 
zation of,  792-794;  in  breasts  of  newly 
born,  918;  fever,  744;  in  newly  born, 
784;  in  pregnancy,  115;  qualitative 
anomalies  of,  761;  "uterine,"  78; 
variations  in  human,   788. 

Miscarriage,   342-361. 

Missed  abortion,  368;    labor,  368. 

Molar   pregnancy,    198. 

Mole,  blood,  195,  345;  flesh,  345;  hydatidi- 
form,  198-201;  placental,  198;  uterine, 
345;  vesicular,  198. 

Monstrosities  of  fetus,  illustrated,  245—254. 

Montgomery's  glands,  prominence  of,  in 
pregnancy,    115. 

Morbidity   in   the    puerperium,    711-759. 

Morning    sickness,    in   pregnancy,    115. 

Morphinism,  effect  of,  on  fetus,  262;  in 
pregnancy,   262. 

Mortality,  in  abortion,  354;  in  accidental 
hemorrhage,  227;  in  accouchement 
force,  1035;  in  asphyxia  of  newly 
born,  856;  in  brow  presentation,  506; 
in  congenital  hydrocephalus,  562;  in 
convulsive  disorders  of  newly-born, 
856;  in  eclampsia,  307,  308,  310,  313; 
in  elderly  primiparae,  666 ;  in  face 
presentation,  517;  in  gestational  cho- 
^sa,  335;  in  infants  in  the  first  year  of 
life,  799;  in  infantile  syphilis,  810;  in 
insanity  of  the  puerperium,  772;  in 
inversion  of  the  uterus,  592;  in  kypho- 
tic pelvis,  645 ;  in  labor  with  vaginal 
obstruction,  612;  in  melena,  849;  in 
miscarriage,  354;  in  Naegele's  pelvis, 
625  ;  in  osteomalacia,  637  ;  in  pelvic  pres- 
entation, 534;  in  pelvic  tumor,  638; 
in  persistent  occipito-posterior  posi- 
tions, 547;  in  persistent  mento-poste- 
rior  positions,  552;  in  penetrating 
wounds  of  the  gravid  uterus,  370;  in 
pregnancy  after  ventrofixation  and 
ventrosuspension,  600;  in  prolapse  of 
umbilical  cord,  525;  in  rupture  of 
uterus,  588,  589;  in  typhoid  fever 
in  pregnancy,  336;  in  version,  936; 
maternal,  in  placenta  prasvia,  218-220; 
of  newly  born,  865,  847. 

Morula,   50. 

Mother's  outfit,   466. 

Moulding,  in  labor,  440;  of  fetal  head,  414; 
in  vertex  presentation,  451—453,  457, 
462. 

Mouth,  formation  of,  58;  of  newly  born 
hild,  cleansing  of,  485;  origin  of,  sto- 
modeal  portion  of,  62. 

Movements  of  fetus,    126,    127. 

Mucosa,  uterine,  characteristics  of,  44; 
normal  thickness  of,  45;  thickness  of, 
in  pregnancy,  45. 

MuUer's  method  of  engaging  fetal  head, 
182;    test  in  pelvic  deformity,  661. 

MuUerian  duct,  formation  of,   61. 

Multigr^vida,    41;     description    of,     137. 

Multipara,  42;    definition,  27. 

Multiple   abscesses,   in   newly   born,    845. 

Multiple  birth,  555-559- 

Multiple  pregnancy,  course  of  labor  in,  555; 
diagnosis  of,  143;  etiology  of,  140; 
hemorrhage   of,    556,    557;    membranes 


INDEX. 


1059 


and  placenta  in,  142,  143;  mummi- 
fication of  fetus  in,  143;  size  of 
children  in,  143;  treatment  of,  556-558. 

Multiple  presentation,   558. 

Mummification  of  fetus,   274. 

Murmur,  cardiac,  in  pregnancy,  115,  n6; 
funic,  129;  umbilical,  in  pregnancy, 
129;     uterine,    in   pregnancy,    124. 

Muscles,  action  of  abdominal,  in  labor,  428; 
changes  of,  in  pregnant  uterus,  103,  104; 
during  puerperium,  676;  formation  of, 
58;    origin  of,  59,  61;    pelvic,  393. 

Myocarditis  in  pregnancy,  326. 

Myoma,  uterine,  cause  of  dystocia,  602,  603; 
Cassarean  section  in,  604;  diagnosis  of, 
603;  diagnosis  of,  from  pregnancy,  134; 
effect  of  pregnancy  on  uterine,  602,  603 ; 
prognosis  of,  603,  604;  treatment  of, 
604. 

Myotome,  58,  61. 

Myxoma  chorii  multiplex,   198-201. 

Myxoma  fibrosum,  201;    of  placenta,  236. 

N. 

Naegele's,  pelvis,  623-626;  forceps,  984; 
rule  for  calculating  date  of  confinement, 
146. 

Naevi,  fetal,    267. 

Nails,  development  of,  85;    origin  of,  61. 

Nausea  in  pregnancy,  115,  299;  in  hydatidi- 
form  mole,  200;  in  phlegmasia  alba 
dolens,   736. 

Navel,  changes  in,  in  pregnancy,    118. 

Neck,  formation  of,  84. 

Neoplasms,  fetal,  270;  uterine,  in  pregnancy, 
282;  .pelvic,  dystocia  from,  638;  ves- 
ical,  in  pregnancy,    135,   319. 

Nephritis,  in  pregnancy,  292,  304;  fetal, 
267 ;  indication  for  prevention  of  repro- 
duction in,  38;    of  newly  born,  810. 

Nerve,  optic,  development  of,  56. 

Nerves,  changes  of  uterine,  in  pregnancy, 
108;  origin  of,  61;  pelvic,  400;  sen- 
sory, origin  of,  56;  sympathetic, 
origin   of,    56. 

Nerve-trunks,  injuries  of,  at  birth,  824-828. 

Nervous  system,  diseases  of,  in  pregnancy, 
333-336;  in  puerperium,  769-773;  dis- 
turbances of,  in  pregnancy,  116;  dur- 
ing puerperium,  677;  origin  of,  61; 
effect  of  menopause  upon,  41. 

Neural  tube,  55,  56. 

Neuralgia,  gestational,  335;  in  hydramnios, 
206;     of   legs,    in   pregnancy,    114. 

Neuritis,  puerperal,  769,  770;  toxic,  in 
puerperium,  740. 

Neuroses,  following  coitus  interruptus,  39; 
following  interrupted  pregnancy,  351; 
in  pregnancy,  335;  fever  from,  in  puer- 
perium, 743. 

Newly  born  child,  779-856;  abscesses,  mul- 
tiple, of,  845;  acute  infectious  diseases 
of,  808;  anasarca  of,  809,  839;  aphthas 
of,  847;  artificial  feeding  of,  788; 
asphyxia  of,  812-823,  atelectasis  of, 
838,  839;  Bednar's  disease  of,  852; 
bladder  and  bowels  of,  795;  blood  of, 
783;  breasts  of,  784;  Buhl's  disease  of, 
851;  Cachexia  of,  855;  cancrum  oris  of, 
843;  care  of,  485,  489,  490,  690,  785; 
changes  in  circulation  in,  780;    chronic 


infectious  diseases  of,  809;  clothing  of, 
786;  colic  of,  852;  constipation  of,  85^, 
854 ;  convulsions  of,  855;  cutaneous  sepsis 
of,  844-846;  cyanosis  of,  816;  cystic 
elephantiasis  of,  809 ;  Dermoid  cysts  of, 
852;  diarrhea  of,  853;  digestion  of, 
782;  diphtheria  of,  808;  diseases  due 
to  bacteria  and  fungi  of,  847 ;  Ecthyma 
of,  845;  endocarditis  of,  810;  envi- 
ronment of,  796;  erysipelas  of,  846; 
establishment  of  respiration  in,  488, 
779;  eyes  of,  485;  Failure  of  circula- 
tion of,  839;  failure  of  digestion  and 
assimilation  of,  840;  feces  of,  781, 
782;  feeding  of,  786-795;  foramen 
ovale  of,  780;  Gastro-enteritis  of,  844; 
gastro-intestinal  sepsis  of,  843 ;  Head 
of,  785;  heart  of,  783;  hemorrhagic 
diathesis  of,  847-850;  hemorrhages 
from  genitals  of  female,  850;  hema- 
turia of,  850;  hydrocephalus  of,  810; 
Ichthyosis  of,  809;  icterus  of,  851; 
inanition  fever  of,  840;  influenza  of, 
809;  intestinal  obstruction  of,  854; 
Length  of,  419;  loss  of  weight  of,  784; 
liver  of,  783;  Malformations  and  mon- 
strosities, of,  807;  marasmus  of,  840; 
mastitis  of,  851;  maternal  diseases  and 
conditions  affecting,  809,  810;  measles 
of,  807;  meconium  of,  781;  medica- 
tion of,  856;  melena  or  gastro-intes- 
tinal hemorrhage  of,  849;  milk  in 
breasts  of,  851;  mortality  of,  799,  847, 
848;  mouth  of,  485;  Nephritis  of,  810; 
noma  of,  843;  nursery  for,  795;  Oblit- 
eration of  bile-ducts  in  the,  810;  oedema 
of,  839;  omphalorrhagia  of,  848;  oph- 
thalmia of,  832-837;  Parotitis  of,  844; 
pathology  of,  799-856;  peritonitis  of, 
810;  periumbilical  pemphigus  of,  844, 
845;  physiology  of  the,  779-796;  pneu- 
monia in  the,  809,  909;  post-mortem 
observations  of,  785;  pulse  of,  781; 
purpura  haemorrhagica  of,  850;  Ranula 
of,  852;  retropharyngeal  abscess  of, 
844;  rheumatism  of,  809;  rickets  of, 
810;  "run  round"  of,  845;  Scarlatina 
of,  808;  sclerema  of,  850;  sepsis  of, 
809,  842;  septic  coryza  of,  843;  septic 
infection  of,  841,  842;  septic  pem- 
phigus of,  844;  signs  of  normal  nutri- 
tion in,  784;  simple  elephantiasis  of, 
809;  sleep  of,  795;  stenosis  of  the 
pylorus  of,  810;  stools  of,  781,  782; 
sublingual  cysts  of,  852;  sudden  death 
of,  856;  syphilis  of,  810-812  ;  tempera- 
ture of,  781;  tetanus  of,  846;  thrush 
of,  847;  tuberculosis  of,  809;  Ulcera- 
tion of  hard  palate  of,  852;  ulcerous 
stomatitis  of,  843;  umbilical  cord  of, 
780;  urine  of,  782;  Variola  of,  808; 
vomiting  of,  852;  weight  of,  784; 
Winckel's  disease  of,   851. 

Nipple,  anatomical  anomalies  of,  759,  760; 
care  of,  in  pregnancy,  187;  care  of,  in 
puerperium,  692;  changes  in,  in  preg- 
nancy, 114,115;  eczema  of,  in  pregnancy, 
291;  fissured,  744,  759;  treatment, 
760;    in  puerperium,   761; 

Noma   of  the   newly   born,    843. 

Nostrils,  origin  of,  61. 

Notochord,  57. 


1060 


INDEX. 


Nullipara,  43;    definition  of,  27. 

Nurse,  obstetric,  470;  asepsis  of,  749;  wet, 
788. 

Nursery,  795. 

Nursing,  length  of  period  of,  787;  of  newly 
born,  maternal,  786-788;  proper  inter- 
vals between  787. 


O. 

Obesity,  cause  of  interrupted  pregnancy, 
348;  tendency  to,  in  menopause,  25, 
36;    menstruation  in,   134. 

Obstetric  bag,  466—469. 

Obstetric  surgery,  858-1037. 

Obstructed  labor  (see  Dystocia). 

Obturator,  internus  muscle,  397;  membrane, 
398. 

Occipito-anterior  position,  left,  451-456; 
right,  456,  457. 

Occipito-posterior  positions,  457-462;  per- 
sistent, 545-550,  treatment  in,  547-550. 

(Edema,  general  fetal,  270;  in  pregnancy, 
130;  neonatorum,  839;  of  legs,  in  preg- 
nancy, 114;  of  placenta,  228,  229;  of 
vulva  and  vagina,  a  cause  of  dystocia, 
613,  969. 

Olfactory  organs,  origin  of,  61. 

Oligohydramnios,  204. 

Omentum,  malignant  growths  of,  diagnosis 
from  pregnancy,  136. 

Omphalorrhagia  of  newly  born,  848;  prog- 
nosis, treatment,  849. 

Oophoritis,  during  puerperium,  730;  fol- 
lowing coitus  interruptus,  38. 

Operations,  choice  between  chloroform  and 
ether  for,  867;  for  correction  of  in- 
juries, 1031-1037;  for  delivery,  963— 
1031;  in  pelvic-floor  lacerations,  1034— 
1037;  i^  pregnancy,  370;  in  rupture 
of  uterus,  589,  590;  preparations  for, 
860,  861;  preparatory  to  delivery,  887- 
962. 

Ophthalmia  neonatorum,  832-837;  preven- 
tion of,  490. 

Opiates  in  colic  of  newly  born,  853;  in 
malignant  peritonitis,  755;  in  puer- 
peral parametritis,  755;  in  puerperal 
perimetritis,  755;  in  psychoses  of  preg- 
nancy, 334;  in  rigidity  of  the  os  uteri, 
607. 

Oral  sepsis  in  pregnancy,  323. 

Organisms  (see  Bacteria). 

Organogenesis,  242. 

Organs,  embryology  of,  54;  enlarged  ab- 
dominal, diagnosis  of,  from  pregnancy, 
136;  formation  of  primitive,  54;  genital 
origin  of,  61;  of  taste,  origin  of,  61; 
olfactory,  origin  of,  61;  tactile,  origin 
of,  61;   urinary,  origin  of,  61. 

Orgasm,  26. 

Orrhotherapy    in     puerperal     sepsis,     751, 

^  752.  .... 

Os  uteri,  ngidity  of,  a  cause  of  dystocia,  606, 
607;  normal  dilatation  of,  during  labor,, 
433;  manual  and  instrumental  dilata- 
tion of,  891;  occlusion  of  the  external, 
a  cause  of  dystocia,  609. 

Osiander's  sign  in  pregnancy,  125. 

Osseous  system,  diseases  of  the,  in  fetal 
syphilis,  260;   in  pregnancy,  340,  341. 


Ossification,  placental,  235. 

Osteomalacia,  634-637;  in  pregnancy,  340, 
341- 

Outlet,  pelvic,  165,  166,  383,  384. 

Ovarian,  cyst,  diagnosis  of,  from  hydram- 
nios,  205,  206;  pregnancy,  361;  tu- 
mors, a  cause  of  dystocia,  604. 

Ovaries,  anomalies  of,  286;  changes  in,  be- 
fore ovulation,  24,  25;  origin  of,  61. 
(See  Graafian  follicles.) 

Ovariotomy,  effect  of,  on  menstruation,  25; 
in  osteomalacia,  635,  636. 

Ovate  pelvis,  623-626. 

Ovoid,  fetal,  421. 

Ovulation,  17;  and  menstruation,  relation 
between,  24,  25;  a  periodic  process,  17; 
nervous  control  of,  25. 

Ovum,  41,  42;  characteristics  of,  in  the  sev- 
eral lunar  months,  83 ;  cystic  disease  of, 
198;  definition  of,  77;  description  of  pri- 
mordial, 78;  deutoplasm  of,  78;  diag- 
nosis of,  from  blood-clot,  354;  diseases 
of,  242,  243;  earliest  human,  65;  de- 
scription of,  82;  fecundation  of,  with 
double  yolk,  140;  fertilization  of,  28; 
in  abortion,  344;  maturation  of,  42; 
metaboUsm  of ,  78;  migration  of ,  18,  23; 
morula  of,  49,  50;  nutrition  of,  78; 
primitive  streak  of,  53;  pronucleus  of, 
42 ;  Reichert's,  69 ;  segmentation  of, 
49 ;  segmentation-nucleus  of,  49 ;  size 
of  mature,  42;  Spee's,  54;  zona  pel- 
lucida  of,  43. 


P. 

Pain,  false  labor,  431,  distinguished  from 
true,  433;  in  accidental  hemorrhage, 
226;  in  deciduoma  malignum,  196;  in 
ectopic  gestation,  363;  in  hydatidiform 
mole,  200;  in  legs,  in  pregnancy,  1x4; 
in  puerperal  infection,  747;  in  uterine 
inertia,  570;  labor,  429,  430,  431;  over- 
strong  labor,  posture  in,  876;  in  pre- 
cipitate labor,  667. 

Pajot's,  law  of  accommodation,  421;  man- 
oeuvre, 998. 

Palate,  time  of  formation  of,  84;  ulceration 
of,  in  newly  born,  852. 

Palpation  in  pelvic  deformity,  656;  of 
uterus,  in  pregnancy,  121. 

Palper-mensurateur,   183. 

Palpitation  in  pregnancy,   327;    treatment 

of,  327- 

Pancreas,  formation  of,  58;    origin  of,  61. 

Paralysis,  auditory,  in  puerperium,  771; 
facial  (see  Facial  Paralysis) ;  gesta- 
tional, 355;  in  puerperal  thrombosis 
and  embolism,  768;  ocular,  in  puer- 
perium, 837;  of  arm  at  birth,  826,  827; 
of  placental  site,  580;  cause  of  inver- 
sion of  uterus,  591;   puerperal,  770. 

Parametritis,  729,  730;  coexistent  with 
perimetritis,  729;    treatment  of,  755. 

Parity,  in  relation  to  interrupted  preg- 
nancy, 347,  348. 

Parotitis,  fetal,  258;  in  newly  born,  844; 
puerperal,  737. 

Parturient  canal,  400,  408;  definition  of, 
400;  diameters  of  the,  444,  445;  shape 
of,  444. 


INDEX. 


1061 


Parturiometer,  431. 

Passages,  the,  375-408. 

Pathology,  embryonal  and  fetal,  242,  243; 
of  labor,  499-671;  of  newly  born,  598- 
856,  due  to  interruption  of  pregnancy, 
800-807,  general  considerations  of,  799; 
of  pregnancy,  199-372;  of  puerperium, 
700-776. 

Patient,  preparation  of,  for  examination  in 
pregnancy,  150;   for  operation,  860. 

Pelvic,   angles,    387;    articulations,    anoma- 
lies of,  710;   binder  in  puerperium,  696 
axis,    387;     cellulitis,    puerperal,     795 
diameters,  comparison  of  different,  388 
disease  in  relation  to  mode  of  life,  37 
floor,    lacerations    of,    5^41:600^     1033- 
1037;    inlet,  description 'oi7~38 1 ;    plane 
of.   385;    joints,   diastasis  of,   cause  of 
dystocia,   615;    exaggerated  motion  or 
separation  of,   639;    functions  of,   379; 
inflammation    of,    in    pregnancy,    340; 
relaxation  of,  in  pregnancy,  340;    out- 
let, description  of,  383;    plane  of,  386; 
planes,  385. 

Pelvic  deformity,  616-665;  abortion  in,  723; 
absolute  contraction  in,  659;  treatment 
in,  659,  660;  avoidance  of  conception 
in,  656;  Cassarean  section  in,  658,  659, 
660,  662,  663,  664;  celibacy  advisable 
in,  656;  cephalometry  in,  661;  classi- 
fication and  description  of  different 
varieties  of,  617,  618;  combined  meth- 
ods of  treatment  in,  664;  cord,  pro- 
lapse of,  in,  654;  cranioclasm  in,  660; 
diet  in,  657,  658;  embryotomy  in,  658, 
659,  660,  [662,  663,  664;  expectant 
method  in,  658,  662;  forceps  in,  658, 
662,  664;  frequency  of,  616;  general 
diagnosis  of,  656;  general  etiology 
and  development  of,  617;  general 
symptomatology  of,  652-655;  indica- 
tion in  absolute,  660;  indications 
in  relative,  662;  induction  of  pre- 
mature labor  in,  657;  labor  prolonged 
in,  653;  laparohysterectomy  in,  664; 
marriageability  of  women  with,  656; 
mensuration  in,  656;  methods  of  man- 
aging dystocia  from,  657;  Muller's 
manoeuvre  in,  663;  Muller's  test  in, 
661;  palpation  in,  656;  parental  char- 
acteristics in,  656;  .  pelvimetry  in,  656; 
pendulous  abdomen  in,  653;  perfora- 
tion in,  662;  Perret's  method  in,  663; 
previous  history  in  diagnosis  of,  656; 
Prochownik's  diet  in,  657,  658,  663; 
prognosis  of,  656;  prophylactic  treat- 
ment in,  656-658;  relative  contraction 
in,  659,  treatment  of,  660-665;  sub- 
jective symptoms  in,  652-655;  statis- 
tics showing  course  of  labor  in,  660, 
662;  symphyseotomy  in,  658,  659,  660, 
662,  663;  therapeutic  abortion  in, 
656;  treatment  of,  656-665,  prophy- 
lactic, 656-65S;  version  in,  662,  663, 
664;  Walcher  posture  in,  662. 

Pelvigraphy,  178. 

Pelvimeter,  Baudelocque's,  162;  Farabeuf's, 
172;  Schultz's,  168;  Skutsch's,  172; 
Stein's,  171. 

Pelvimetry,  external,  162-167,  S^o;  L5h- 
lein's  measurement  in,  175;  indirect, 
by    measuring    the    sternum,     17S;     in 


pelvic  deformity,  656;  in  labor,  474; 
internal,  167-177;  internal  manuaj 
175,  176,  177;  objects  of  internal,  167; 
ROntgen,  177. 

Pelviotomy,  936. 

Pelvis,  as  influenced  by  age,  389,  390;  as 
influenced  by  dress,  36;  anatomical,  375; 
anomalies,  due  to,  defective  develop- 
ment, 618-630,  as  a  result  of  disease 
of  the  pelvic  bones,  618,  629-639,  due 
to  disease  of  superimposed  parts  of  the 
skeleton,  618,  641—649,  due  to  disease 
of  the  weight-bearing  parts  of  the  skele- 
ton, 618,  649-652,  due  to  fractures, 
638,  in  junction  of  pelvic  bones,  639, 
640;  articulations  of,  376;  assimila- 
tion, 649,  650;  axes  of,  387;  Blood- 
vessels of,  399,  400;  bones  of,  375,  376; 
bony,  375,  376;  Cavity  of,  382;  cellular 
tissues  of,  399;  clinical  measurement 
of,  422;  cordiform,  635;  coxalgic, 
649;  Definitions  of,  375;  deformed, 
general  symptomatology  of,  652-655; 
disease  of,  due  to  abortion,  39,  in  rela- 
tion to  marriage,  37,  38;  Exostoses  of, 
638;  measurements  of,  162-167,  380- 
385,  472;  external  surface  of,  379; 
False,  380;  forces  leading  to  the  pro- 
duction of  the  adult,  390-393;  func- 
tions of,  393;  Generally  contracted 
fiat,  non-rachitic,  621;  glands  of,  399, 
400;  Inclination  of,  38  7;  infantile. 
390,  618;  inlet  of,  381;  internal  sur- 
face of,  379;  Joints  of,  376;  justo- 
major,  627;  justo-minor,  618;  juvenile, 
390;  Ligaments  of,  3 98;  lordosis  of,  649; 
lymphatics  of,  399,  400;  Male,  389; 
muscles  of,  393;  Naegele's,  623-626; 
funnel-shaped,  621;  nerves  of,  400; 
new  growths  of,  638;  Obliquely  de- 
formed or  contracted,  623-626;  ob- 
turator membrane  of,  398;  -osteoma- 
lacic, 634,  635;  outlet  of,  383-384; 
Planes  of,  385-387;  postures  which 
alter  shape  of,  868-871 ;  postures  which 
elevate,  871-876;  Prague,  641,  643; 
pseudo-osteomalacic,  63 1 ;  rachitic, 
629-634;  Robert's,  626;  Scoliotic,  647; 
sex  in  relation  to,  389;  sexual  differ- 
ences in,  389;  simple  flat,  non-rachitic, 
620;  simple  fiat,  rachitic,  631-633; 
size  and  shape  of,  factors  influencing, 
389;  soft  parts  of,  393-400;  split,  627; 
spondylolisthetic,  641-643;  true,  380, 
3S1. 

Pemphio;us,  acutus,  neonatorum,  844;  peri- 
umbilical, of  newly  born,  844,  845; 
puerperal,  740. 

Penoy^e's  forceps,  984. 

Peptogenic  milk  powder,  components  and 
reaction  of,  794. 

Peptonuria  in  pregnancy,  319;  in  puer- 
perium, 676. 

Perforation  (see  Craniotomy),  944-946;  in 
accidental  hemorrhage,  228;  in  after- 
coming  head,  946;  in  bregma  presenta- 
tion, 946;  in  brow  presentation,  946; 
in  congenital  hydrocephalus,  563;  in 
face  presentation,  946;  in  pelvic  de- 
formity, 626,  660;  in  pelvic  presentation, 
946 ;  in  threatened  rupture  of  the  uterus, 
589;     in   tumors   causing   absolute   ob- 


1062 


INDEX. 


struction   to   delivery,    604;     in   vertex 

presentation,  946;   indications  for,  943, 

944;    operations  of,  944-946. 
Pericarditis,  puerperal,  737. 
Pericardium,  formation  of,  60. 
Perimetritis,  731,  732;    puerperal,  731,  732; 

diagnosis  of,  from  parametritis,   733. 
Perineal  lacerations,  1033;    repair  of,  1033- 

1037- 

Perineum,  central  perforations  of,  1033, 
repair  of,  103 3-1 03  7;  inspection  and 
repair  of,  490;  preservation  of,  during 
delivery  of  shoulders,  486;  protection 
of,  during  second  stage  of  labor,  481-485. 

Peritoneum,  changes  of,  in  pregnancy,  109. 

Peritonitis,  a  result  of  curettage  in  puer- 
peral infection,  756;  encysted,  diag- 
nosis of,  from  pregnancy,  136;  of 
fetus,  260,  263;  of  newly  bom,  810; 
puerperal,  730-783;  puerperal,  benign 
forms  of,  730,  731;  circumscribed,  730; 
general,  735-738;  genesis  of,  733; 
puerperal,  mahgnant,  733-735;  diag- 
nosis and  prognosis  of,  837,  838; 
etiology  of,  733;  symptoms  of,  733; 
treatment  of,  755. 

Periuterine  inflammation  and  adhesion  dur- 
ing pregnancy,  281. 

Pernicious  ansemia,  an  indication  for  pre- 
mature delivery,  890. 

Perret's  method  of  cephalometry,  180;  in 
pelvic  deformity,  661. 

Pessary,  in  retroflexion  of  gravid  uterus,  278. 

Peter's,  embryo,  45,  65;  ovum,  descrip- 
tion of,  82. 

Pharynx,  origin  of,  61. 

Phlebitis,  in  pregnancy,  241;  puerperal, 
cellulitic,  735,  736;  puerperal,  femoral, 
733.  737;  puerperal,  septic,  735,  736; 
puerperal,  uterine,  735,  736. 

Phlegmasia  alba  dolens,  736,  737;  a  result 
of  curettage,  756. 

"Phobias,"  in  pregnancy,  333,  334. 

Phthisis  (see  Tuberculosis). 

Physician,  asepsis  of,  150,  749,  750;  duties 
of  family,  39.  ; 

Physician's  obstetric  bag,  466,  467.  i 

Physiological  pregnancy,  41-188. 

Physiology  of  newly  born,  779-796. 

Physometra,  after  putrefaction  of  fetus 
274;   diagnosis  of,  from  pregnancy,  133. 

Pigmentation,  cutaneous,  in  pregnancy,  114, 
115,  117,  118,  125,  130,  338;  of  genitals, 
in  pregnancy,  89. 

Placenta,  70-71;  accidental  hemorrhage 
from,  224-228;  adhesions  of,  233,  234; 
and  membranes,  delivery  of ,  102 5-1029; 
angioma  of,  237;  annular,  209;  anom- 
alies, 208-215;  apoplexy  of,  229-231, 
345,  a  cause  of  ante-partum  hemor- 
rhage, 372;  atrophy  of ,  209;  Battledore, 
212,  213;  bilobed,  209;  Calculi  o±,  235; 
circular  vein  of,  71;  circulation  of,  70- 
77;  cotyledons,  71;  Crede's  method  of 
expressing,  491,  1025-1028;  curling 
arteries  of,  71;  delivery  of,  439;  in 
Caesarean  section,  1015;  Degeneration 
of,  233-236;  dimensions  of,  71;  dis- 
eases of,  208—237;  duplex,  210;  Eman- 
uel's disease  of,  231,  232;  examination 
of,  492;  expulsion  of,  in  case  of  twins, 
557;  Fenestrated,  209;  fetal  surface  of, 


71;  formation  of,  65,  70;  functions  of. 
70,  78,  79;  Haematoma  of,  229-231; 
horseshoe,  209;  hyperplastic  changes  in, 
233;  hypertrophy  of,  209;  In  albumi- 
nuria, 319;  in  ectopic  gestation,  366; 
infarcts  of,  229-231,  234;  infectious 
granulomata  of,  232,  233;  inflamma- 
tion of,  231,  232;  injuries  of,  224—228; 
interstitial  hemorrhage  of,  229-231;  in 
twin  pregnancy,  142,  143;  Lobate,  209; 
low  implantation  of,  216,  a  cause  of 
intrapartum  hemorrhage,  671;  mal- 
formation of,  in  placenta  praevia,  216; 
manual  extraction  of,  1029;  marginata, 
213;  membranacea,  222 ;  multiple,  209, 
210;  Origin  of,  84;  ossification  of,  235; 
Pigment  deposits  in,  236;  polypi  of, 
236,  237;  prsevia,  214-224,  diagnosis 
of,  217;  Treatment  of,  220-224;  pre- 
mature detachment  of  a  normally  situ- 
ated, 224—228;  retention  of,  492,  493, 
574-577,  in  miscarriage,  355;  Sclerotic 
changes  in,  233;  secondary  altera- 
tions in,  233-236;  separation  of,  cause 
of  ante-partum  hemorrhage,  372;  site 
of,  71,  paralysis  of,  580;  syphilis  of 
232,  233;  Thrombosis  of,  229;  trans- 
mission of  disease  by  (see  Antenatal  dis- 
ease of  fetus),  255-272,  807-813;  tu- 
berculosis of,  232;  tumors  of,  236,  237; 
weight  of,  71,  as  related  to  fetal  weight, 
209;    white  infarcts  of,  234,  235. 

Placentitis,  231,  232;    varieties  of,  231,  232. 

Planes,  pelvic,  385-387;    of  fetal  trunk,  419. 

Pleurae,  formation  of,  60. 

Pleuritis,  in  pregnancy,  329;   in  puerperium. 

737- 

Pleuropneumonia,  septic  purulent,  of  the 
newly  born,  843. 

Pneumococcus  sepsis,  of  fetus,  258. 

Pneumonia,  aspiration,  832;  coexistent  with 
labor,  668;  in  fetus,  258;  in  pregnancy, 
257,  258;  septic  of  newly  born,  809,  843. 

Podalic  version,  925-936. 

Poisoning,  acute,  of  fetus,  261,  262;  cause 
of  fetal  death,  272;  chronic,  in  preg- 
nancy, 262;    of  newly  bom,  809. 

Poisons,  elimination  of,  in  eclampsia,  311; 
effect  of,  on  spermatozoa,  28. 

Polygalactia,  685,  761;   treatment  of,  761. 

Polyhydramnios,  204—208. 

Polymazia,  759. 

Polypi  after  abortion,  356;  intracervical, 
cause  of  antepartum  hemorrhage,  372; 
placental,  236,  237;  uterine,  diagnosis 
of,  from  inversion  of  uterus,  291. 

Polyspermism,  28. 

Polyuria  in  pregnancy,  319. 

Porro-Caesarean  section,  102 0-1022. 

Portio  vaginalis,  changes  in,  in  pregnancy, 
147. 

Posenheim's  formula  for  rectal  feeding.  303. 

Position  of  fetus,  425—428;  definition  of, 
425;  English,  French,  and  German 
classification  of  vertex,  426;  diagnosis 
of,  154-162;  frequency  of  first  vertex, 
explained,  426;  left  vertex,  occipito- 
posterior,  persistent,  545;  persistent 
mento-posterior,  550-553;  relative  fre- 
quency of  each,  426;  transverse,  538; 
transverse,  of  the  head  at  the  pelvic 
outlet.  553,  554. 


INDEX. 


1063 


Postmortem  Caesarean  section,  1025. 
Posture  in  obstetrics,  868. 
Pregnancy,     abdominal     ballottement     in, 
125,    126;     binder   in,    194;     abnormal, 
191;  abnormal  age  of ,  21,  22;  abnormal 
conditions  in  twin,  143;  abnormal  crav- 
ings in,  116;    accidents  and  injuries  in, 
369,  370;    acetonuria  in,   320;    acne  in, 
337;  acute  nephritis  during,  315;    after 
operations    involving     the    genitals    in,    1 
370;  after  ventrofixation  and  ventrosus- 
pension,  600;  albuminuria  in,  11 7,  304, 
307,  319;  alcoholism  in,  262;  alopecia  in, 
339;  amaurosis  in,  116,  335;  amblyopia 
in,    116;    anemia    in,    117;    abdominal 
tumor  in,  137;  appendicitis  in,  137,  370; 
ascites  in,  136;  bladder  in,  112-114,  130, 
137;   floating  kidney  in,  137;   hydrosal- 
pinx in,   141;     displaced  liver  in,    137; 
and  lactation,  relation  between,  25;  and 
ovarian  tumor,  135,  139;    pelvic  tumors 
in,  137;  pyosalpinx  in,  137;    and  tuber- 
culosis,  329-331;  and  tumor  of  broad 
ligament,    137;  ventral  hernia  in,    137; 
aneurism  in,  327;  anorexia  in,  322;  ante- 
flexion of  uterus  in,  274,  2 7 5 ;_ anthrax 
in,     258;     areola,     secondary    in,     115; 
asthma  in,  332;  Bacteriology  of  vagina 
in,  148,  149;  ballottement  in,  128;  binder 
in,  187;    blood  in,  328;    bowels  in,  186; 
breasts  in,  126,  187;  bronchitis  in,  329; 
Cancer  in,  263;  cardiac  diseases  in,  263; 
care  of  nipples  in,   187;  cephalalgia  in, 
335;    cephalometry   in,    180-184;    cere- 
bral disease  in,   332;  cervical  canal  in, 
9 1 ;  cervical  consistence  in,  89 ;  cervical 
softening    in,    89,    123;    cervix    in,    89; 
changes  in  abdomen  in,  125,  in  bladder 
in,  112,  113,  114,  in  blood  in,  117,  188. 
in  breasts  in,  114,  115,  126,  187,  in  cer- 
vix in,  89,  90,  91,  147,  in  cranial  cavity 
in,  118,  in  disposition  in,  116,  in  gait  in, 
118,  in  liver  in,  116,  in  lower  extremi- 
ties in,    114,  in  lungs  in,    116,  in  lym- 
phatic glands  in,  116,  in  navel  in,  118, 
of    ovarian    artery    in,    108,    in    pelvic 
joints  in,   114,  340,  341,. in  portio  vag- 
inalis in,  147,  in  rectum  in,  114,  in  skin 
in,  117,  in  spleen  in,  116,  in  symphysis 
in,   114,  in  urine  in,   117,  in  uterus  in, 
91-113,  120,   125,  in  vagina  in,   125,  in 
vulva  in,'i25;  chloasma  of,  117;  cholera 
in,  257;  chorea  in,  335;  chyluria  in,  320; 
cliseometry   in,    178;   clothing   in,    187; 
constipation   in,    115,    323;    corsets   in, 
187;     contractions,     uterine,     intermit- 
tent,   in,   123;    cough  in,   331;    cramps 
of  legs  in,  114;    cravings  in,  115;    cys- 
titis  in,    316,    317;     cystocele    in,    289; 
Deafness  in,  335;  death,  sudden,  in,  369; 
death  of  fetus  in,  272;  dementia  in,  116; 
diabetes  in,  262;   diagnosis  of,  119-133; 
differential  diagnosis  of,  132-138;  diag- 
nosis  of  fetal   position,    154-162;   diar- 
rhoea in,  115,  324;  diet  in,  186;  diseases 
of  the  alimentary  tract  in,  321-325,  of 
the  circulatory  system  in,   325-329,   of 
the  genital  organs  in,   274-290,  of  the 
nervous    system    in,    332-336,    of    the 
osseous    s3'-stem    in,    340-342,    of    the 
respiratory  system  in,  329-332,  of  the 
urinary  tract  in,   315-321;  duration  of. 


144-146;  during  lactation,  121;  douches 
in,  187;  drink  in,  186;  dyspnoea  in,  11 6, 
331;  dysuria  in,  317;  Eclampsia  in,  304- 
314;     ectopic     (see    Ectopic    gestation); 
ectopic   and   normal   pregnancy,    coex- 
istence  of,    136;   eczema   in,    291,    337; 
emphysema    in,    329;     endocarditis    in, 
325,  326;  endometritis  in,  193,  194;  en- 
teralgia  of,  323;    epilepsy  in,  335;    ery- 
sipelas  in,   256,   336;     examination   in, 
148-184;  excitement,  avoidance  of,  in, 
188;  exercise  in,  185,  186;  exopthalmic 
goitre  in,  328;  extrauterine  (see  Ectopic 
gestation,     361);     Feigned,     138;     fetal 
heart,  location  of,   161;    fever  of,  371; 
fibroid  tumors  in,  282;   Gastric  and  in- 
testinal indigestion  of ,  115,323;   general 
phenomena   of,    115-119;   gingivitis   in, 
321;    glycosuria    in,    319,    320;    gonor- 
rhoea in,  289;    headache  in,  335;  heart- 
bum   in,   115,    324;    heart    changes   in, 
115,    116,    326;    Hegar's    sign   in,   123; 
hematocele      in,      326;     hematuria    in, 
319;     hemorrhoids   in,   324;     hernia  in, 
118;    hernial    protrusions  of  uterus  in, 
281;    herpes    in,     338,     339;     Braxton 
Hicks'  sign  of,  123;  hydrsemia  in,  327; 
hydronephrosis    in,    316;    hydrophobia 
in,   258;    hygiene  and  management  of, 
184-188;    hyperosmia  in,  329;  hysteria 
in,   335;  Icterus  in,   293,   303;  idiosyn- 
crasies in,  1S8;  impetigo  in,  339;  incon- 
tinence of  urine  in,  318;  indigestion  in, 
115;    infectious    diseases   in,    336,    337; 
influenza  in,  257;  injuries  and  accidents 
in,  369,  370;  insanity  of,  323,  332-334; 
insomnia  in,  334;  interrupted,  39,  342- 
361,  888-906,  displacements  after,  356 
duration  of,  352,  etiology  of,  348-350, 
frequency  of,  345,  346,  hemorrhage  m, 
354.    355.   immediate   dangers   of,    354, 
neuroses  following,  357,  prophylaxis  of, 
357,    prognosis   of,    354,    psychoses   fol- 
lowing, 357,  recurrent  interruptions  of, 
350,  relative  frequency  of,  349.  remote 
dangers    of,   356,     subinvolution    after, 
356,  symptoms  of,  350-352,  table  of  sta- 
tistics of,   349,    treatment  of,  357-361; 
irritability,    mental,    in,     188;    Jacque- 
mier's  sign  of,   125;  kidney,  floating,  in, 
316;  kidney,  incarceration  of,  in,   316; 
jaundice  in,  303,   324;  Kidnej^  of,   292; 
hypodermoclysis  in,  864;  Labiaein,  89; 
lactosuria  in,  319;  latero-flexion  in,  278; 
latero-version  in,   278;    leucocytosis  in, 
120;  leucorrhea  in,  187,  288,  289;  leuke- 
mia  in,   263;   lineae  albicantiae  in,  117; 
lipuria  in,  320;  longings  of,  323;    lower 
extremities  in,  130;  lungs  in,  116;    Ma- 
laria in,   257,   258,   337;   malformations 
of    genital  organs  in,    282-2S8;    mam- 
mary abscess   in,    291;    mania  in,  116; 
measles  in,    191,   256,  336;  melancholia 
in,    116;    menstruation   in,    23;   mental 
condition  in,  188;  mercuriaUsm  in,  262; 
metritis  in,   281,  282;  metrorrhagia  of, 
371,  372;  milk  secretion  in,  115;  molar, 
198;     Montgomery's     glands    in,     115; 
morbid  appetite  in,  115;  morphinism  in 
262,  263;  multiple,   140-144;  eclampsia 
in,  304-314;  murmurs,  cardiac,  in,  116; 
umbilical,  in,  119,  uterine,  in,  124;  Nau- 


1064 


INDEX. 


sea  and  vomiting  in,  115,  299-303;  ne- 
phritis, chronic  in,  315;  neuralgias  in, 
114,335;  neuroses  in,  114,  335;  oedema 
in,  114,  130,  290;  operations  in,  370;  oral 
sepsis  in,  322;  osteomalacia  in,  340; 
Palpation  in,  123,  154-162;  paralyses 
ii^'  335;  pathological,  191-372;  pel- 
vigraphy in,  178;  pelvimetry  in,  162— 
178;  peptonuria  in,  319;  peri-uterine 
inflammation  and  adhesion  in,  281; 
pernicious  anaemia  in,  328;  pernicious 
vomiting  in,  3  00 ;  phenomena  in  maternal 
organism  produced  by,  89-119;  phle- 
bitis in,  326;  pleurisy  in,  329;  pneu- 
monia in,  258,  337;  poisoning,  acute 
in,  261;  poisoning,  chronic  in,  262; 
polyuria  in,  319;  position  of  uterus 
in  different  months  of,  125;  prioritus 
in,  290,  337;  psoriasis  in,  337;  psychic- 
al changes  in,  116;  puerperal  osteo- 
phytes in,  118;  pyelonephritis  during, 
316;  pyorrhoea  alveolaris  in,  322; 
pyrosis  of,  323;  quickening  in,  126; 
Rasch's  sign  of,  124;  relapsing  fever 
in,  258;  relaxation  of  pelvic  joints 
in,  340;  renal  calculi  in,  316;  renal  insiif- 
ficiency  in,  292;  respiration  in,  116; 
Salivation  in,  322;  scarlatina  in,  256, 
336;  sciatica  in,  130;  sebaceous  follicles 
in,  89 ;  secretions  of  genitals  in,  89 ; 
sense-perception  in,  116;  sense  perver- 
sion in,  188;  sepsis  in,  258;  sexual  inter- 
course in,  188 ;  signs  of,  1 19-132 ;  abdom- 
inal, 125,  126;  classification  of,  accord- 
ing to  months,  131,  132  ;  cutaneous,  130; 
doubtful,  131;  fetal,  126-129;  mam- 
mary, 126;  positive,  131;  pressure  and 
congestion,  130;  probable,  131;  sub- 
jective, 130;  sympathetic  and  reflex, 
129;  uterine,  120—125;  vaginal,  125; 
skin,  care  of,  in,  186,  187;  skin  diseases 
in,  337—340;  sternum,  indirect  pelvim- 
etry by  measurement  of,  178;  striae 
atrophicae  after,  678;  stris  in  breasts 
in,  114;  sweat  glands  in,  89;  syncope  in, 
^27;  symptoms  of  (see  Signs  of);  syph- 
ilis in,  232,  233,  337;  Teeth,  care  of,  in, 
321,  322;  teeth,  caries  of,  in,  321;  throm- 
bosis in,  768;  toxemia  of,  291-299, 
clinical  types  of,  296,  and  eclampsia, 
differences  between,  296,  diagnosis  of, 
297,  298,  etiology  of,  293,  294,  path- 
ogeny of,  294,  295,  pathological  an- 
atomy of,  292,  symptomatology  of ,  295, 
treatment  of,  298-303;  tuberculosis  in, 
258,  259,  acute  miliary  in,  331;  twin, 
explanation  of,  141,  142;  typhoid  fever 
in,  256,  257;  Unconscious,  139;  uremia 
in,  307;  urine  in,  117,  examination  of, 
in,  1S8,  retention  of,  in,  318;  uterine  and 
cornual,  coexistence  of,  137;  uterus  in, 
91-113,  prolapse  of,  in,  279;  retrover- 
sion and  retroflexion  of,  in,  275-277, 
rupture  of,  in,  282,  torsion  of,  in,  280; 
uterus,  incarceration  of,  in,  277—279; 
spontaneous  rupture  of,  in,  282; 
Vaccination  in,  336;  vaccinia  in,  256; 
vagina  in,  89;  vaginal  examination  in, 
149,  167-177;  vaginal  pulse  in,  92; 
vaginitis,  cystic,  in,  289;  vaginitis,  spe- 
cific in,  289;  varicosities  in,  89,  114, 
130,  290,  326;  variola  in,  255,  256,  336; 


vertigo  in,  334;  vesical  calculi  in,  318; 
vesical  hemorrhoids  in,  319;  vesical 
irritation  in,  316,  317;  vomiting  in,  118, 
299-303;    vulval  vegetations  in,  290. 

Premature  births,  percentage  of,  800. 

Premature  labor,  artificial,  in  pelvic  de- 
formity, 658-665;  indications  for  the 
induction  of,  890,  891;  method  advised 
for  the  induction  of,  895. 

Premature  rupture  of  the  membranes,  cause 
of  dystocia,  605. 

Prematurity,  800-807;  bathing  in,  803; 
clothing  in,  803;  estimation  of  degree 
of,  802;  etiology  of,  800,  801;  feeding 
in,  803-805;  incubation  in,  871,  872; 
physiological  peculiarities  of,  801,  802; 
prognosis  of,  802;  symptoms  of,  801; 
treatment  of,  802-807. 

Prepuce,  adhesion  of,  796;  management  of, 
in  newly  born,  796. 

Presentation,  abnormal,  in  multiple  preg- 
nancy, 144,  and  prolapse  of  cord,  522— 
527,  878;  breech,  527-538;  bregma, 
500-503;  brow,  503-508;  cause  of  ver- 
tex, 423;  classification  of  varieties  of, 
423;  definition  of,  421;  frequency  of 
the  several  varieties  of,  423;  multiple  or 
compound,  558;  parietal,  anterior  and 
posterior,  518,  519;  pelvic,  527-538; 
shoulder,  538-545;  vertex,  450-463. 

Primipara,  41;  definition  of,  27;  diagnostic 
points  of,  138;  signs  of  recent  delivery 
in,  687,  688. 

Primiparse,  labor  in  elderly,  665-667. 

Primitive  streak,  53,  55,  58. 

Prochownik's,  diet  in  pelvic  deformity,  657; 
method  of  artificial  respiration,  822. 

Proctitis,  puerperal,  727. 

Prolapse,  of  arm,  520-522,  in  shoulder  pre- 
sentation, sling  in,  935,  1009,  posture 
of  mother  in,  879;  of  cord,  522-527, 
breech  extraction  in,  969,  podalic  ver- 
sion in,  925,  sling  in,  1009;  of  legs,  522; 
of  pregnant  uterus,  279,  effect  of,  on 
fetus,  271;  of  uterus  in  puerperium, 
710. 

Pronucleus,  female,  42;  male,  43. 

Protargol  solution  in  ophthalmia  neona- 
torum, 835,  836. 

Proteids,  regulation  of,  in  modified  milk, 
789,  790. 

Pruritus,  hiemalis,  338;  in  menstruation,  21; 
in  pregnancy,  33;  vulvae,  in  pregnancy, 
290. 

Pryor's  iodine  treatment  in  puerperal  infec- 
tion, 752,  753. 

Pseudo-fever,  puerperal,  743. 

Psoas  magnus  muscle,  395. 

Psoas  parvus  muscle,  395. 

Psoriasis  in  pregnancy,  337. 

Psychosis,  acute,  in  labor,  668;  following  in- 
terrupted pregnancy,  357;  Korsakoff's, 
769;  puerperal,  771-773. 

Ptyalism  in  pregnancy,  322. 

Puberty,  20;  signs  of,  20. 

Pubic  ligaments,  398. 

Pubis,  306,  375;  arch  of,  384. 

Puerperae,  care  of,  40. 

Puerperal  infection,  747-749;  antistrepto- 
coccic serum  in,  750;  endometritis  iru, 
718-727;  orrhotherapy  in,  752,  753, 
sapremia   in,    738,    739;    symptoms    of. 


INDEX. 


1065 


747,  748;  treatment  of,  749-759;  ulcers 
in,  718. 
Puerperium,  abdominal  binder  in,  695; 
abdominal  muscles,  diastasis  of,  in, 
711;  metastatic  abscesses  in,  737;  acute 
specific  diseases  in,  713;  after-pains  in, 
674,  691;  air  embolism  during,  776; 
albuminuria  in,  676;  anemia  in,  714, 
768,  769;  antistreptococcic  serum  in, 
750,  751;  aphasia  in,  771 ;  asepsis  in,  689, 
690,  749,  750;  atrophy  'of  uterus 
during,  673,  709;  auditory  paralysis  in, 
771;  Bacterial  toxemia  in,  739,  740; 
bacteriemia  in,  741,  with  toxemia  in, 
741;  bacteria  in  uterus  in,  716;  blood 
condition  in,  677,  768;  blood-states  in, 
73S-742;  bowels  in,  676;  breasts,  an- 
omalies of,  in,  759;  breast  changes  in, 
683;  care  of  the  bladder  in,  691,  692; 
of  the  bowels  in,  692 ;  of  the  breasts  and 
nipples  in,  692;  of  the  mother  in,  690; 
Cellulitis  in,  737;  cervix  and  cervical 
canal  in,  678;  changes  in  uterine  adnexa 
in,  683;  changes  in  uterus  in,  679-683; 
chill,  post-partum,  673;  cholera  in, 
738;  chronic  toxemia  not  due  to  preg- 
nancy in,  713,  714;  constipation  in,  705, 
739,  743,  744;  corset  in,  698;  cystitis  in. 
707,  727;  Decidua  during,  682;  defini- 
tion of,  673;  diagnosis  of,  687,  688;  diet 
in,  693,  694;  digestion  in,  676;  diph- 
theria in,  737,  738,  740;  diseases  of 
breast  in,  761-768;  diseases  originating 
intragenitally  in,  737,  738;  diseases  of 
nervous  system  in,  769— 773  j  duration  of , 
673;  Effects  of  dystocia  in,  714;  em- 
bolism in,  768,  776;  emotional  ex- 
citement, cause  of  fever  in,  745 ; 
endocarditis  in,  741,  742;  endome- 
tritis in,  718-727;  ergot  in,  697; 
eruptions  of  septic  infection  in,  773; 
erysipelas  in,  737;  examination  of,  698, 
750;  excision  of  veins  in,  758;  exercise 
in,  697,  698;  exhaustion  in,  673;  exter- 
nal genitals  in,  677,  678;  Fever  in,  746, 
due  to  mammary  irritation  in,  744, 
due  to  neurotic  conditions  in,  745,  746, 
due  to  reflex  irritation  in,  744-746,  due 
to  uterine  displacements,  745,  due  to 
uterine  rupture,  744;  Galactocele  in, 
768;  general  diseases  in,  773;  general 
phenomena  in,  673-677;  genital  tract, 
anomalies  of,  in,  708-710;  glycosuria 
in,  319,  320;  gonorrheal  infection  in, 
737;  Heart  in,  677;  heart  murmur  in, 
674;  hematuria  in,  705,  706;  hemiplegia 
and  aphasia  in,  771;  hemorrhoids  in, 
705;  hyperinvolution  in,  709,  710;  hy- 
perthermia in,  743—747;  hypothermia 
in,  747;  hysteria,  cause  of  fever  in,  745; 
Impregnation  in,  687;  infections,  con- 
secutive focal  in,  727-741;  infections, 
primary  focal  in,  718-727;  inflamma- 
tions, genital,  extragenital,  and  peri- 
genital,  in,  714;  insanity  in,  771-773; 
intestinal  anomalies  in,  705;  involution 
in,  679-6S3;  Kidneys  in,  676;  Lacto- 
suria  in,  676;  lochia,  in,  678;  lochio- 
colpos  in,  714;  local  phenomena  of, 
677-687;  Mammary  irritations  in,  744; 
management  of,  688-698;  massage  in, 
697;  mastitis  in,  762-768;  medication  in, 


691,  697;  metastatic  lesions  in,  738;  me- 
tritis in,  728,  729;  metrophlebitis  in,  735, 
736;  milk  secretion  in,  683-687,  anoma- 
lies of,  in,  760,  761;  muscles  in,  676; 
morbidity  in,  711-759;  bacteriology 
of,  716;  classification  of,  712;  clinical 
types  of,  713,  747-749;  statistics  of, 
712;  morbid  conditions  of,  antedating 
labor,  713,  714;  morbid  conditions  orig- 
inating in,  716-747;  resulting  from 
labor,  714-716;  mortality  of,  increased 
by  chronic  toxemias  not  due  to  preg- 
nancy, 714-715;  myelitis  and  para- 
plegia in,  771;  Nervous  system  in,  677; 
neuritis  and  paralysis  in,  669-671;  neu- 
ritis, toxic,  in,  740;  sore  nipples  in,  747, 
761;  Ocular  paralysis  in,  771;  oedema  of 
genitals  in,  677 ;  oophoritis  in,  755;  Pain 
in  genitals  in,  673 ;  parametritis  in,  729- 
755 ;  pathological,  701-776;  pelvic  arti- 
culations in,  676,  677;  pelvic  binder  in, 
696;  pemphigus  in,  740;  peptonuria 
in,  676;  pericarditis  in,  737;  perito- 
nitis in,  730-735;  phlebitis  in,  735- 
737;  phlegmasia  alba  dolens  in,  736; 
physiological,  673-698;  placental  site 
in,  682;  pleurisy  in,  737;  posture  in, 
694,  879;  proctitis  in,  727;  professional 
visits  in,  690;  prophylaxis  in,  695-698; 
pseudo-fever  in,  743;  psychoses  in,  771- 
773;  ptomainemia  in,  738,  739;  pul- 
monary embolism  in,  7  7  5 ,  cause  of  sudden 
death  in,  775;  pulse  in,  674;  pyelitis  in, 
727;  pyelonephritis  in,  707;  pyemia  in, 
741;  respiration  in,  675;  rest  in,  690; 
Salpingitis  in,  728;  sapremia  in,  738, 
739;  sapremic  sepsis  in,  742,  743; 
septicsemia  in,  741,  742;  septic  blood- 
states  in,  741-742;  septic  erythema  in, 
740;  shock  from  dystocia  in,  714;  skin 
in,  675,  676,  diseases  of,  in,  773;  ster- 
coremia  in,  739;  stomach  in,  676;  sub- 
involution of  uterus  in,  708;  submam- 
mary abscess  in,  767;  sudden  death  in, 
773-776;  superinvolution  in,  709;  syn- 
cope and  shock  cause  of  sudden  death 
in,  774;  Temperature  in,  675,  711,  712; 
thrombosis  in  735,  775;  tuberculosis  in, 
714;  tympanites  in,  764;  Urea  excretion 
in,  676;  urethritis  in,  727;  urinary 
anomalies  in,  705-707;  urine  in,  676, 
incontinence  of,  in,  706;  retention  of, 
in,  676,  679,  691,  692,  706,  uterine 
adnexa  in,  683;  uterine  displacement 
in,  710;  uterine  muscle  in,  682;  uterine 
souffle  in,  675;  uterine  vessels  in,  682; 
Vagina  in,  678;  variola  in,  738. 

Pulmonary,  arterj-,  fetal,  81,  arteries,  prim- 
ary thrombosis  of,  in  puerperium,  776, 
disease,  effect  of,  on  labor,  668,  embol- 
ism, cause  of  sudden  death  in  puer- 
perium, 775. 

Pulse ,  funic ,  7  7 ;  in  placental  hemorrhage  ,226; 
in  colic  of  newly  born,  852;  in  convul- 
sions of  newly  born,  855;  in  eclampsia. 
306;  of  newly  bom,  781;  in  malignant 
peritonitis,  734;  in  puerperal  fever,  747; 
in  puerperal  infection,  747;  in  insanity 
of  puerperium,  772;  in  labor,  431;  in 
prematurity,  802;  in  puerperium,  674; 
in  pulmonary  embolism,  775;  in  septic 
infection  of  newly  bom,  841;  in  tetanus 


1066 


INDEX. 


of  newly  born,  846 ;  vaginal,  in  preg- 
nancy, 89,  125;  in  sapremia,  739;  in  sep- 
ticemia, 741;  uterine,  in  pregnancy,  124. 

Purpura  hsemorrhagica  of  newly  born,  849. 

Purpura,  puerperal,  773. 

Putrefaction  of  fetus,  274. 

Pyelitis  in  puerperium,  727. 

Pyelonephritis,  in  pregnancy,  316;  in  puer- 
perium,  727. 

Pyemia,  a  result  of  curettage  in  puerperal 
infection,  752;  puerperal,  741;  types  of, 

747- 
Pylorus,    congenital    hypertrophic    stenosis 

of,  263,  810. 
Pyogenic  cocci  in  bacterial  toxemia,  739. 
Pyometra,    diagnosis    of,    from    pregnancy, 

133- 
Pyorrhoea  alveolaris  in  pregnancy,  322. 
Pyosalpinx,  and  pregnancy,  coexistence  of, 

.137- 
Pyriformis  muscle,  397. 
Pyrosis  of  pregnancy,  323. 


Q. 

Quickening,  in  pregnancy,  126;  the  relation 
of,  to  the  vomiting  of  pregnancy,  299. 

Quinine,  as  accelerator  of  first  stage  of  labor, 
572;  in  malaria  of  pregnancy,  257; 
in  puerperal  infection,  751;  in  puer- 
perium, 697. 

R. 

Races,  intermarriage  of,  a  factor  in  maternal- 
fetal  dystocia    656. 

Rachidotomy,   946. 

Rachitic  pelves,  629-634. 

Rachitis  (see  Rickets). 

Radiography,  metric,   178. 

Rales  in  lungs  of  newly  born,  842. 

Ranula  of  newly  born,  852. 

Rape,  29-35. 

Rasch's  sign  in  pregnancy,  124. 

Rauber's  layer,  53,  63,  64,  65. 

Rectal,  feeding  in  pernicious  vomiting  of 
pregnancy,  303,  infusion  of  saline  solu- 
tion, 861,  862,  syringes  for  newly  born, 
?54. 

Recti,  separation  of,  in  puerperium,  711. 

Rectocele,  cause  of  dystocia,  614,  615. 

Rectum,  changes  in,  in  pregnancy,  114; 
disturbances  in,  in  pregnancy,  130; 
distended,  cause  of  dystocia,  613,  614; 
repair  of,   1036*,  1037. 

Reflex  irritation  a  cause  of  hyperthermia, 

744,   745- 

Reichert's  ovum,  69. 

Relapsing  fever,  in  pregnancy,  258;  of  fetus, 
258. 

Renal  calculi  in  pregnancy,  316. 

Renal  disease,  effect  of,  on  fetus,   263. 

Renal  insufficiency,  in  pregnancy  (see  Tox- 
emia of  pregnancy). 

Rennet,  action  of,  685. 

Repositors  for  prolapsed  small  parts,  918. 

Reproduction,  indications  for  prevention  of, 

Respiration,  artificial,  in  asphyxia  neona- 
torum, 819-823;  character  of,  in  labor, 
431,  in  prematurity,  801,    802,    803,   in 


puerperium,  675,  691;  establishment  of, 
in  newly  born,  488,  779;  rate  of,  at 
birth,  779. 

Respiratory  system,  diseases  of,  in  preg- 
nancy, 329-332. 

Rest,  in  puerperium,  747. 

Retention,  of  placenta  and  membranes,  574- 
577;    of  urine  in  puerperium,  737,  748, 

749.  765- 

Retina,  formation  of,  56;  origin  of,  61. 

Retraction  of  the  uterus  in  "dry  labor,"  570. 

Retraction  ring  (see  Contraction  ring). 

Retroflexion  and  retroversion  of  uterus  in 
puerperium,   710. 

Retroflexion  of  uterus,  diagnosis  of,  from 
pregnancy,  135;  in  pregnancy,  275-278; 
and  incarceration,  an  indication  for  in- 
duction of  abortion,  278. 

Retropharyngeal  abscess  in  newly  born,  844. 

Retroversion  of  uterus,  diagnosis  of,  from 
pregnancy,  135;  in  pregnancy,  276-278. 

Rheumatism  in  newly  born,  809;  of  fetus, 
258;  of  uterine  muscle  in  pregnancy, 
281. 

Rickets,  629-634;  cause  of  constipation  in 
newly  born,  854;  cause  of  convulsions 
in  newly  bom,  855;  fetal,  629,  630,  810; 
in  lower  animals,  630. 

Rigidity  and  atresia  of  vagina  and  vulva, 
cause  of  dystocia,  610-612. 

Ring,  Bandl's,  402;  contraction,  402;  re- 
traction, 451;  umbilical,  780. 

Ritgen's  method  of  extracting  forecoming 
head,  965,  966. 

Ritter's  disease,  844. 

Robert's  pelvis,  626. 

Roederer's  obliquity,  451,  499. 

Rokitansky,  "cervical  pregnancy"  of,  196; 
"puerperal  osteophytes"  of,  118;  pelvis 
of,  641—643. 

RSntgen,  cephalometry,  184;  pelvimetry,  177, 
178. 

Rostrate  pelvis,  635. 

Rotation,  digital,  in  transverse  position  of 
head  at  pelvic  outlet,  554;  excessive,  of 
occiput,  in  vertex  presentation,  454; 
dangers  from  forceps,  990;  of  fetal  head, 
413 ;  of  first  part  of  fetal  ellipse  in  labor, 
442-446 ;  of  second  part  of  fetal  ellipse  in 
labor,  446,  447;  posterior,  of  occiput,  and 
impaction,  459,  460. 

Rotators,  forceps  as,  1002. 

Round  ligaments,  changes  of,  in  pregnancy, 
III. 

Rubber  gloves,  151. 

Rupture,  of  membranes,  premature,  dysto- 
cia from,  605;  of  membranes,  tardy, 
dystocia  from,  605 ;  of  pelvic  floor, 
muscular,  597;  spontaneous,  of  uterus, 
in  pregnancy,  282. 

Rupture  of  uterus,  584-590;  celiotomy  in, 
589;  following  ventrofixation  of  uterus, 
600,  601;  in  contracted  pelvis,  655;  in 
pregnancy,  584;  in  pregnancy  in  cancer- 
ous uterus,  610;  in  puerperium,  584; 
intra-partum,  584. 


S. 
Sac,  amniotic,  66. 

Sacral  plexus,  lesions  of,  during  puerperium, 
769. 


INDEX. 


1067 


Sacro-coccygeal,  joint,  378;  symphyseotomy 
in  ankylosis  of,  937;  synostosis  at, 
639;  ligaments,  398;  tumors,  cause  of 
dystocia,  564,  565. 

Sacro-iliac  joints,  diastasis  of,  in  labor,  615; 
movements  in,  378;  synostosis  at,  639. 

Sacro-posterior  cases,  persistent,  delivery  of 
head  in,  979,  980. 

Sacro-sciatic  ligaments,  398. 

Sacro-vertebral,  angle,  378;  joint,  426. 

Sacrum,  375,  376;  imperfect  development  of, 
623-626;  molaility  in  joints  of,  379. 

Saline  infusion,  861 ;  intra-arterial,  862 ;  intra- 
venous, 862,  863;  in  eclampsia,  312;  in 
post-partum  hemorrhage,  584;  prepara- 
tion of  solution  for,  861;  in  puerperal 
infection,  751;  umbilical,  in  asphyxia 
neonatorum,  823;  rectal,  in  shock,  861, 
862;  vaginal  and  intrauterine,  881,  882. 

Salines,  in  overdistention  of  breast,  744;  in 
puerperal  constipation,  744. 

Salivation  in  pregnancy,  322. 

Salpingitis,  puerperal,  728. 

Saponification  of  fetus,  274. 

Sapremia,  antepartum,  713;  puerperal,  720, 
721,  738,  739,  748;  from  neglect  of  ex- 
cretions in  adolescence,  36. 

Saprophytes  in  puerperal  endometritis,  719- 
721. 

Sarcomata,  fetal,  270;  pelvic,  638. 

Saw  decapitator,  958. 

Scales,  baby,  787. 

Scanzoni's,  cephalotribe,  953;  manoeuvre, 
1006. 

Scarlatina  of  fetus,  256;  in  newly  born,  808; 
in  pregnancy,  256. 

Schultze's  measurements  of  embryo  and 
fetus,  86,  87,  88;  method  of  artificial 
respiration,  820,  821 ;  method  of  placen- 
tal delivery,  439;  sickle  hook,  956,  957. 

Sciatica,  in  pregnancy,  130. 

Scissors,  decapitation,  959. 

Sclerema  neonatorum,  850. 

Sclerosis  of  placenta,  233. 

Scoliotic  pelvis,  647. 

Sebaceous  follicles  in  pregnancy,  89. 

Secundines,  retention  of,  492,  493. 

Sedatives,  in  convulsions  of  newly  born,  855; 
in  insanity  of  puerperium,  773;  in  puer- 
peral neuritis,  770;  in  threatened  abor- 
tion, 358;  in  painful  labor,  572. 

Segmentation  of  the  ovum,  53. 

Semen,  27. 

Semmelweiss  on  puerperal  fever,  148. 

Senses,  acute,  in  pregnancy,  116;  perversion 
of,  in  pregnancy,  18S. 

Sepsis,  acute  puerperal,  747 ;  bacteria  of  puer- 
peral, 148,149,741,  742;  a  sequel  of  labor 
in  typhoid  fever,  336;  conditions  which 
predispose  to,  722;  fetal,  25S;  in  newly 
born,  809 ;  in  pregnancy,  258 ;  in  relation 
to  psychoses  in  pregnancy,  334;  puer- 
peral, gas,  742;  puerperal,  sapremic,  726, 
742;  treatment  of,   749;  umbilical,  842, 

843- 

Septa,  decidual,  origin  of,  71;  of  vagina,  a 
cause  of  dystocia,  612. 

Septic,  coryza  of  newly  born,  843 ;  infection, 
in  interrupted  pregnancy,  355,  of  newly 
born,  809,  841-847,  puerperal,  organisms 
causing,  721,  722,  puerperal,  treatment 
of,     753-755;  neuritis,    puerperal,    741; 


pemphigus  of  newly  born,  844 ;  phlebitis, 
puerperal,  735;  pneumonia  of  newly  born, 
809, 843- 

Septicaemia,  741,  742;  clinical  phenomena 
of,  741;  primary  foci  of  puerperal,  741; 
puerperal,  741;  venosa,  puerperal,  735, 
736. 

Septicopyemia,  puerperal,  723,  742. 

Serotina,  decidual,  45. 

Serous  cachexia  in  pregnancy,  327. 

Serum,  antistreptococcic,  in  puerperal  infec- 
tion, 750,  751,  752. 

Sex,  as  indicated  by  fetal  heart-beat,  161; 
influence  of,  on  weight  of  newly  born,  784, 
850. 

Sexual,  intercourse,  a  cause  of  abortion,  188, 
effect  of,  on  health,  36,  37,  effect  of,  on 
menstruation,  2  2 ,  effect  of,  on  ovulation, 
17,  in  pregnancy,  188,  life,  36,  37; 
functions,  hygiene  of,  35,  36. 

Shock,  enteroclysis  in,  864;  from  dystocia, 
714;  from  post-partum  hemorrhage, 
treatment  of,  584;  treatment  of,  in  as- 
phyxia neonatorum,  823. 

Short  cord,  posture  of  mother  in,  878. 

Shoulder  presentation,  538-544;  bipolar  po- 
dalic  version  in,  926,  927;  combined 
cephalic  version  in,  922,  923;  definition 
of.  538,539;  diagnosisof,  543,  544;  etiol- 
ogy of,  539,  540;  evisceration  in,  960; 
frequency  of,  539,  540;  mechanism  and 
course  of  labor  in,  540-543;  palpation 
in,  161;  podalic  version  in,  925-927,  935; 
prognosis  of,  544;  synonyms  of,  538; 
treatment  of,  544. 

Shoulders,  delivery  of,  456,  486-488,  966-968. 

Show,  in  labor,  431,  435. 

Sickle  knife  decapitator,  558. 

Silver,  nitrate,  as  preventive  of  ophthalmia, 
490;  in  aphthas  of  the  newly  born,  847; 
Credo's  coUodial,  in  endometritis,  754; 
in  ecthyma  neonatorum,  845  ;  in  gonor- 
rheal stomatitis,  837;  in  leucorrhea,  187; 
in  ophthalmia  neonatorum,  834,  835; 
in  treatment  of  sore  nipples,  761  762;  in 
umbilical  sepsis,  842,  843. 

Simple,  flat,  rachitic  pelvis,  631;  non-rachitic 
pelvis,  620,  621. 

Simpson's,  cranioclast,  947;  forceps,  984. 

Sims',  dilator,  904,  knee-chest  posture,  87a. 

Sinciput,  409,  411. 

Skiagraphy,  pelvic,  178.  (See  ROntgen 
Pelvimetry  and  Rontgen  cephalometry.) 

Skin,  care  of,  in  pregnancy,  1S7,  in  relation 
to  hygiene  of  sexual  functions,  36; 
changes  of,  in  pregnancy,  117;  diseases, 
in  pregnancy,  337-340,  in  puerperium, 
675,  676;  formation  of,  55,  58;  in  fetal 
syphilis,  260. 

Skull,  fetal,  measurements  of,  1S0-1S4,  pre- 
mature ossification  of,  562. 

Skutsch's  pelvimeter,  171. 

Sling,  indications  and  uses  of,  1007;  in  pelvic 
presentation,  1008;  in  placenta  praevia, 
1009;  in  prolapse  of  cord,  1008;  in  pro- 
lapse of  an  arm  in  shoulder  presentation, 
935,  1009;  in  combined  podalic  version, 
1009. 

Small  parts,  fetal,  location  of,  by  palpation, 
156.  157;  reposition  of  prolapsed,  916, 
917. 

Smallpox.      (See  Variola.) 


106S 


INDEX. 


Smellie-Veit  method  in  breech  presentation, 
978-980. 

Solayre's  obliqmty,  451. 

Somatopleura,  63;  formation  of,  58. 

Souffle,  funic,  in  pregnancy,  129;  uterine,  in 
pregnancy,  124,  in  puerperium,  675. 
(See  Murmur.) 

Spee's  embryo,  83. 

Spermatozoa,  27,  28;  as  affected  by  acids,  28, 
by  alcoholism,  28,  by  alkalies,  28,  by 
cold,  28,  by  heat,  28,  by  sexual  excesses, 
28;  appearance  of,  27;  ascent  of,  28; 
disappearance  of,  28,  motion  of,  27,  28; 
age  for  first  appearance  of,  28;  rate  of 
motion  of,  28;  theories  of  ascent  of,  28; 
vitality  of,  28. 

Sphincter  and  muscle,  external,  398. 

Spina  bifida,  265,  266. 

Spinal,  anesthesia  in  labor,  868;  cord,  origin 
of,  61;  disease  in  relation  to  labor,  668. 

Splanchnopleure,  64;  formation  of,  59;  origin 
of,  61. 

Spleen,  changes  of,  in  pregnancy,  116;  ef- 
fect of  hepatic  insufficiency  on,  326; 
floating,  cause  of  dystocia,  605,  diagnosis 
of,  from  pregnancy,  137;  in  septic  in- 
fection of  newly  bom,  841;  rupture  of, 
in  labor,  669. 

Spondylolisthesis,  641—643. 

Spondylolizema,  643. 

Spondylotomy,  963. 

Spurious  pregnancy,  138. 

Staphylococci,  in  human  milk,  789;  in  puer- 
peral sepsis,  149;  in  vulval  canal,  149; 
sepsis  of  fetus  due  to,  258 

Stercoremia,  puerperal,  739. 

Sterility,  after  abortion,  356;  artificial,  37; 
following  coitus  interruptus,  38;  from 
displacements  of  the  uterus,  275,  276; 
posture  in  coitus,  an  aid  in  overcoming, 
876. 

Sterilization  of  instruments  and  dressings, 
860,861;  of  milk,  789,  793. 

Sternomastoid,  hematoma  of,  832. 

Stoltz's  sign  of  death  of  fetus,  273;  test  for 
vaginal  hernia,  667. 

Stomatitis,  gangrenous,  of  newly  born,  843; 
gonorrheal,  837;  ulcerous,  of  newly  born, 
843 ;  vesicular  or  follicular  of  newly  bom, 

847. 

Stools  of  newly  born.  (See  Feces  of  newly 
born.) 

Strait,  inferior,  definition  of,  383;  superior, 
definition  of,  381. 

Streak,  primitive,  53,  54,  58. 

Streptococcus,  erysipelatis,  846;  pyogenes 
in  puerperal  sepsis,  149,  in  vulval  canal, 
149,  in  fetal  sepsis,  258. 

Striae,  abdominal,  in  pregnancy,  125;  atro- 
phicas,  after  pregnancy,  678;  of  breast 
in  pregnancy,  114. 

Strychnin,  after  abortion,  361;  in  asphyxia 
neonatorum,  823;  in  eclampsia,  312;  in 
erysipelas  of  the  newly  born,  846;  in 
heart  disease  of  pregnancy,  326;  in  last 
weeks  of  pregnancy,  573;  in  puerperal 
infection,  751;  in  puerperium,  697. 

Subinvolution,  708;  causes  of,  192,  356,  708; 
diagnosis  of,  708,  diagnosis  of,  from 
pregnancy,  133;  treatment  of,  708. 

Sublingual  cysts  in  the  newly  bom,  852. 

Sudamina,  puerperal,  773. 


Sudden  death,  in  pregnancy,  296,  369;  ac- 
couchement force  in,  965;  podaUc  ver- 
sion in,  925,  in  puerperium,  773-776;  of 
newly  laorn,  856,  857. 

Sugar,  regulation  of,  in  modified  milk,  789- 

o       795- 

Superfetation,  140,  141. 

Surgery,  obstetric,  859-1037. 

Sweat  glands,  in  pregnancy,  89. 

Sylvester's  modified  method  of  artificial  res- 
piration, 821. 

Symphyseotomy,  937-941;  French  or  open 
method  of,  941;  Italian  or  suprapubic 
method  of,  939,  940;  subcutaneous  or 
American  method  of,  941. 

Symphysis  pubis,  376;  changes  of,  in  preg- 
nancy, 114,  377;  measurement  of  length 
of ,  in  pregnancy,  166;  synostosis  at,  639. 

Syncope  and  shock,  cause  of  sudden  death  in 
puerperium,  774;  treatment  of,  774; 
following  labor,  580;  in  hydatidiform 
mole,  200;  in  pregnancy,  327. 

Synostosis,  at  sacro-iliac  joints,  639;  at  sac- 
rococcygeal   joint,    639;  at    symphysis, 

639- 
Syphilis,  an  etiological  factor  m  fetal  death, 
272,  cause  of  interrupted  pregnancy, 
337,  348,  349;  congenital,  259—261,  810; 
in  pregnancy,  259-261,  337;  indication 
for  prevention  of  reproduction,  38;  in- 
fantile, 809,  810-812;  diagnosis  of,  810, 
prognosis  of,  811;  treatment  of,  812,  of 
placenta,  232;  of  umbilical  cord,  241; 
treatment  of,  in  pregnancy,  261;  trans- 
mission of,  to  fetus,  260. 


T. 

Tactile  organs,  origin  of,  61. 

Tampon,  uterine.  885,  886;  uterine  and  cer- 
vical, 902;  vaginal,  884,  893;  medicated, 
contraindicated  in  pregnancy,  289. 

Tamponade,  in  accidental  hemorrhage,  228; 
in  inversion  of  uterus,  592;  in  rupture 
of  uterus,  589,  590;  of  uterine  cavity, 
893 ;  of  vagina  and  cervix,  893. 

Tapeworm,  in  pregnancy,  325;  a  cause  of 
fever  in  puerperium,  745. 

Tamier's,  embryotome,  956,  forceps,  984, 
incubator,  805,  sign  of  abortion,  352. 

Taste,  delicacy  of,  in  pregnancy,  116. 

Taste,  organs  of,  origin  of,  61. 

Teeth,  caries  of,  in  pregnancy,  321;  develop- 
ment of,  84;  extraction  of,  in  pregnancy, 
370. 

Temperature,  constipation  a  cause  of  irregu- 
lar, 743,  744;  mammary  irritation  a  cause 
of,  744;  in  labor,  431,  in  puerperium, 
675,  691;  fetal,  781;  in  eclampsia,  306; 
in  pregnancy,  118;  in  puerperal  infec- 
tion, 747;  in  sclerema  neonatorum,  850; 
of  genitalia,  in  pregnancy,  125  ;  of  newly 
born,  781;  of  premature  child,  801;  a 
test  of  a  pathological  puerperium,  711; 
subnormal  (see  Hypothermia). 

Tenesmus,  vesical,  in  pregnancy,  114. 

Testicles,  time  of  descent  into  scrotum,  88. 

Tetanus,  after  interrupted  pregnancy,  355; 
bacterial  toxemia  of,  740;  in  pregnancy, 
258;  of  newly  born,  846,  847;  puerperal, 
740. 


INDEX. 


1069 


Thorax,  formation  of,  60. 

Thrombosis,  in  pregnancy,  327;  infective, 
735-737;  of  placenta,  229-231;  of  pul- 
monary arteries,  primary,  puerperal, 
733,  736,  776;  of  umbilical  arteries,  240; 
vaginal  and  vulval,  cause  of  dystocia, 
613. 

Thrush  of  newly  born,  847. 

Thymus  gland,  in  fetal  syphiUs,  260;  origin 
of,  61. 

Thyroid  extract  in  osteomalacia,  636. 

Toothache  in  pregnancy,  322,  335. 

Topography,  uterine,  at  term,  112. 

Torsion  of  pregnant  uterus,  280. 

Touch,  sense  of,  acute,  in  pregnancy,  116. 

Toxemia,  bacterial,  739,  clinical  course  of 
malignant,  742;  and  fever,  without  sep- 
sis, 748;  a  cause  of  interrupted  preg- 
nancy, 348,  349;  of  pregnancy,  291-299, 
persistent  in  puerperium,  713,  blood  in, 
294,  297,  cUnical  types  of,  296,  Ewing's 
theory  of,  292,  kidney  in,  292,  liver  in, 
292,  spleen  in,  292,  symptoms  of,  295, 
treatment  of,  298-303. 

Toxemias,  chronic,  in  puerperium,  not  due 
to  pregnancy,  713,  714. 

Tracheotomy  in  asphyxia  neonatorum,  817. 

Traction-straps  in  labor,  574. 

Transverse  diameter,  of  pelvis,  383;  of  pel- 
vic outlet,  384. 

Transverse  head,  deep,  forceps  in,  1006,  1007. 

Transverse,  position,  538,  of  the  head,  at 
pelvic    outlet,    553,    554;  presentation, 

538-545- 

Trans  versus  perinei  muscle,  398. 

Traumatism,  fetal,  269;  in  etiology  of  acci- 
dental hemorrhage,  225;  fetal,  birth, 
823-832,  of  brain  and  cord,  823,  824;  of 
nerve-trunks,  824-828;  maternal,  716; 
surgical  treatment  of,  after  labor,  464, 

465- 

Trendelenburg  posture,  875,  879. 

Trendelenburg-Walcher  posture,  879. 

Triple  labor,  management  of,  557. 

Trismus  uteri,  cause  of  dystocia,  606. 

Trunk,  development  of,  54;  dystocia  from 
affections  of,  fetal,  564;  expulsion  of,  in 
labor,  455,  488;  internal  rotation  of,  in 
labor,  446,  460. 

Tubal  abortion,  pathology  of,  364;  preg- 
nancy, 361,  pathology  of,  362,  363. 

Tube,  eustachian,  61;  neural,  55,  56. 

Tuberculosis,  acute  miliary,  in  pregnancy, 
331;  cause  of  interrupted  pregnancy, 
349;  and  pregnancy,  258,  259,  329-331; 
in  newly  born,  809;  an  indication  for 
premature  delivery,  331 ;  in  puerperium, 
714;  an  indication  for  prevention  of  re- 
production, 38;  of  fetus,  258,  259;  of  pla- 
centa, 232;  pregnancy  a  predisposing 
cause  of,  329,  330. 

Tuberculous  toxemia,  fetal,  259. 

Tubes,  ovarian,  condition  of,  in  menstruation, 
2 1 ;  distended,  diagnosis  of,  from  preg- 
nancy, 136. 

Tumors,  coexistence  of  abdominal,  ovarian, 
and  pelvic  with  pregnancy,  136-138;  con- 
genital, of  umbilical  cord,  241,  242;  orig- 
inating in  urinary  apparatus,  cause  of 
dystocia,  564;  diagnosis  of,  from  preg- 
nancy, 135;  pelvic,  638,  dystocia  due  to, 
564,  638,  prognosis  of,  638,  treatment  of, 


638;  placental,  236;  removal  of,  in  preg- 
nancy, 370;  uterine,  ovarian,  renal,  and 
peritoneal,  cause  of  dystocia,  602-605. 

Twin  labor,  hemorrhage  after  first  birth  in, 
556; management  of,  556,  557. 

Twin  monstrosities,  general  fetal  oedema  in, 
270. 

Twin  pregnancy,  common  in  elderly  primi- 
parae,  665 ;  diagnosis  of,  from  hydram- 
nios,  207. 

Twins,  abnormal  conditions  in,  143;  expla- 
nation of,  141;  fetal  heart-beat  in,  161; 
fetal  membranes  of,  142;  management 
of,  556,  557. 

Typhoid  fever  in  pregnancy,  256,  257;  of 
fetus,  257. 

Typhus,  fetal,  258;  in  pregnancy,  336. 


U. 

Ulcer,  puerperal,  718. 

Ulceration  of  hard  palate  in  newly  born,  852. 

Umbilical  arteries,  fetal,  82;  thrombi  in,  240. 

Umbilical  cord,  71-77,  adenomata  of,  242; 
anomalies  of,  237-242;  arteries  of,  77; 
arterial  valves  of,  77;  atheromata  of, 
241-242;  battledore  insertion  of,  237; 
calcareous  deposits  in,  240;  care  of,  486, 
489,  786;  central  insertion  of ,  237;  about 
neck  of  child,  238,  486;  cysts  of,  240; 
dermoids  of,  241;  development  of,  71; 
diameter  of,  77 ;  dressing  for,  786;  eccen- 
tric insertion  of,  237;  entero-teratomata 
of,  242;  epithelium  of,  71;  excessively 
long,  559;  false  knots  in,  77;  formation  of, 
60 ;  function  of ,  7 1 ,  7  7 ;  hsematoma  of ,  2  4 1 ; 
hemorrhage  from,  241,  hernia  of,  240; 
hypertrophy  of  valves  of,  241 ;  infection 
of,  842.  843;  insertion  of,  237;  knots  of, 
238;  lateral  insertion  of,  237;  length  of, 
77,  237;  ligation  of,  488,  489;  in  prema- 
turity, 802;  marginal  insertion  of,  237; 
obstruction  of  vessels  of,  241;  origin  of, 
65,  71;  prolapse  of,  522-527;  in  con- 
tracted pelvis,  654;  pulse  of,  77;  reposi- 
tion of  prolapsed,  916,  1009;  rupture  of, 
560;  short,  559,  symptoms  and  treat- 
ment of,  559,  560;  stenosis  of  vessels  of, 
240;  strength  of.  77,  structure  of,  71; 
syphilitic  lesions  of,  241;  tangling  of, 
238,  239;  thickness  of,  237;  torsion  of, 
239;  traction  on,  cause  of  inversion  of 
uterus,  591;  tumors  ot,  241,  242;  veins 
of,  77;  velamentous  insertion  of,  237; 
venous  valves  of,  77. 

Umbilical,  infusion  in  asphyxia  neonatorum, 
823;  murmur  in  pregnancy,  129;  sepsis. 
842;  stump  and  ring,  780,  781;  vein,  81, 
82;  dilatation  of,  241,  stenosis  of,  240; 
vesicle.  71. 

Umbilicus,  congenital  tumors  of,  241;  dif- 
ference between  male  and  female,  781. 

Unconscious  delivery,  449,  450. 

Urachus,  origin  of,  68. 

Urea,  changes  in,  in  relation  to  eclampsia, 
308;  excretion  of,  in  menstruation, 
20,  in  puerperium,  676;  in  liquor  amnii, 
66. 

Uremia  in  pregnancy,  307;  and  eclampsia, 
difference  between,  307. 

Ureter,  changes  in,  in  pregnancy,  114. 


1070 


INDEX. 


Urethra,  malformations  of,  287;  origin  of, 
61. 

Urethritis,  pyogenic  puerperal,  727. 

Urinary,  anomalies  in  puerperium,  705-707; 
organs,  origin  of,  61;  retention,  in 
pregnancy,  318;  tract,  diseases  of,  in 
pregnancy,  315,  puerperal  infection  of, 

Unne,  examination  of,  in  pregnancy,  188, 
308,  309;  fetal  excretion  of,  66,  67; 
fetal,  albumin  in,  79;  in  cystitis,  707;  in 
eclampsia,  307;  in  newly  born,  782;  in 
pregnancy,  117,  importance  of  ex- 
amination of,  188;  in  puerperium,  676; 
in  toxemia  of  pregnancy,  295;  retention 
of,  676,  679,  691;  incontinence  of,  in 
pregnancy,  114,  318;  in  distended 
bladder,  134;  prenatal,  67;   toxicity  of, 

30?- 

Urogenital,  apparatus,  fetal  diseases  of,  267; 
ystem,  origin  of,  60,  61. 

Urotropin  in  puerperal  cystitis,  754. 

Utero-sacral  ligaments,  changes  in  preg- 
nancy, III. 

Uterus,  absent,  283;  accessory,  286;  ante- 
flexion and  anteversion  of,  in  pregnancy, 
274,  275;  asymmetry  of,  in  pregnancy, 
loi;  atrophy  of,  during  lactation,  709; 
axial  torsion  of,  42  7 ;  Backward  displace- 
ments of,  427:  bacteriology  of,  716; 
Bandl's  ring  of,  402;  bicornis,  preg- 
nancy in,  367;  Cancer  of,  cause  of 
dystocia,  610;  capacity  of,  at  fortieth 
week,  673,  at  end  of  puerperium,  673; 
catheterization  of  (Krause's  method), 
891-893;  changes  of,  in  labor,  429,  430, 
in  menstruation,  21,  in  pregnancy,  91- 
112,  in  puerperium,  673,  679-686;  changes 
in  arteries  of,  106—108,  in  axis  of, 
102,  103,  in  consistence  of,  103,  123, 
in  contractility  of,  1 1 1 ,  in  fibrous  tissue 
of,  105,  in  irritability  of ,  iii,  350,  in  liga- 
ments of,    109-111,     in  lymphatics   of, 

108,  in  nerves  of,  108,  in  muscular 
layers  of,   103,   104,    in  peritoneum   of, 

109,  in  position  of,  102,  in  sensibility  of, 
III.  in  shape  of,  100,  loi,  in  size  of, 
92-100,  in  veins  of,  106,  107,  in  walls 
of,  112;  congenital  prolapse  of,  267, 
286;  congenital  retroflexion  of,  286; 
congestive  hypertrophy  of,  diagnosis 
of,  from  pregnancy,  134;  contractile 
power  of,  persistent  after  death, 
670;  contractions  of,  in  labor,  429, 
in  post-partum  hemorrhage,  583,  584, 
in  second  stage  of  labor,  437-439, 
in  third  stage  of  labor,  439;  contraction 
ring  of,  402,  403;  cordate,  in  pregnancy, 
287,  288;  digital  exploration  of,  880; 
Duplex,  283 ;  Excessive  right  lateral 
obliquity  of,  592;  Fetal  and  infantile, 
286;  fluctuations  of,  in  pregnancy,  124; 
Hernial  protrusion  of,  in  pregnancy,  281 ; 
Incarceration  of  pregnant,  275,  277,  278; 
inertia  of,  566,  568-574;  in  pregnancy, 
94-112;  involution  of,  in  puerperium, 
679-683;  Lateral  displacements  of, 
in  pregnancy,  279;  Malformations  of, 
in  pregnancy,  282,  283,  287,  288;  multi- 
parous,  description  of,  137,  138;  murmur 
in,  in  pregnancy,  124;  muscle  of,  in 
puerperium,   682;     Non-development  of 


maternal,  effect  of,  on  fetus,  271;  non- 
pregnant, enlargements  of,  132,  133; 
Origin  of,  60;  Parturient,  proper- 
ties of,  216;  penetrating  wounds  of 
gravid,  370;  perforation  of,  in  curet- 
tage after  interrupted  pregnancy,  355, 
356;  position  of,  in  different  months  of 
pregnancy,  102;  pregnant,  parts  of, 
216;  prolapse  of  pregnant,  279,  280; 
puerperal,  description  of,  137,  138,  687; 
Retraction  of,  571;  retrodisplacements 
of,  275-278,  a  cause  of  fever  in  puer- 
perium, 744,  effect  of,  on  fetus,  275,  276; 
rheumatism  of  muscle  of,  in  pregnancy, 
281;  rudimentary,  284,  285.;  rupture  of, 
584-590;  a  cause  of  fever,  744,  diag- 
nosis of,  from  accidental  hemorrhage, 
226,  227;  in  osteomalacia,  342;  Spon- 
taneous, 370;  spontaneous  in  pregnancy, 
282;  shape  of,  in  different  months  ,86,87; 
sinking  of,  in  labor,  432;  size  of,  at  end 
of  puerperium,  673,  at  fortieth  week 
of  pregnancy,  673,  in  different  months 
of  pregnancy,  86,  87;  souffle  in,  in 
pregnancy,  124;  Tetanoid  action  of, 
571;  tetanoid  state  of,  566;  topo- 
graphical relations  of,  at  term, 
112;  torsion  of,  in  pregnancy,  280; 
trismus  of,  cause  of  dystocia,  606;  uni- 
cornis, in  pregnancy,  288,  367;  Vessels 
of,  in  puerperium,  682;  virgin,  94; 
Walls  of,  in  labor,  404,  405 ;  weight  of,  at 
end  of  puerperium,  673,  at  fortieth 
week  of  pregnancy,  673. 


V. 

Vaccination  in  pregnancy,  336. 

Vaccinia  in  pregnancy,  256;   of  fetus,  ,256. 

Vagina,  abnormal  conditions  of,  a  cause  of 
dystocia,  668,  669;  absent,  286,  287; 
atresia  of,  a  cause  of  dystocia,  610- 
612;  bacteriology  of,  148,  149,  716; 
changes  of,  in  pregnancy,  152;  color  of,  in 
pregnancy,  89 ;  condition  of,  in  menstrua- 
tion, 2 1 ;  deformities  of, 28 7 ;  development 
of,  60,  61 ;  disinfection  of,  in  forceps  opera- 
tion, 989;  in  puerperium,  678;  exami- 
nation by,  in  pregnancy,  149,  167-177; 
hernia  of,  667;  incisions  of,  909,  910; 
in  pregnancy,  89 ;  lacerations  and  con- 
tusions of,  594,  595,  repair  of,  1032- 
1037;  nialignant  disease  of,  cause  of 
antepartum  hemorrhage,  372;  ob- 
struction of,  treatment  of,  612;  origin  of, 
61;  prolapse  of,  in  pregnancy,  289; 
rudimentary,  286,  287;  secretions  of,  in 
pregnancy,  148;  treatment  of  obstruc- 
tion of,  612. 

Vaginal  and  vulval  thrombosis,  cause  of  dys- 
tocia, 613. 

Vaginal,  Caesarean  section,  1022-1025,  drain- 
age in  puerperal  sepsis,  756;  douche,  88 1 ; 
examination  in  pregnancy,  149, 167—177; 
hernia,  667;  irrigation  in  puerperal  en- 
dometritis, 726;    tampon,  884,  893. 

Vaginismus,  cause  of  dystocia,  610. 

Vaginitis,  cystic,  in  pregnancy,  289;  granu- 
lar, in  pregnancy,  89;  specific,  in  preg- 
nancy, 289. 

Vaginofixation,  labor  after,  602. 


INDEX. 


1071 


Vagino-perineal  incision,   910,   911. 

Vagino-perineal  lacerations,   597,    1033. 

Valve,  eustachian,  81,  82. 

Vaporization  in  septic  endometritis,  758;  in 
septic   phlebitis,    755. 

Varicosities,  in  pregnancy,  89,  130,  290,  326; 
of  umbilical  vein,  241 ;  rupture  of,  cause 
of  intrapartum  hemorrhage,  671. 

Variola,  in  newly  born,  808;  in  pregnancy, 
25s.  33^'>  of  fetus,  225;  puerperal, 
738. 

Vas  deferens,  origin  of,  60. 

Vectis,  915. 

Vegetations,  vulval,  in  pregnancy,  290. 

Vein,  effect  of  air  in,  862;  placental  "circu- 
lar," 71;  primitive,  jugular,  81 ;  umbili- 
cal,   8r,    82. 

Veins,  excision  of,  in  puerperal  infection, 
758;  infusion  of,  in  puerperal  infection, 
751;   omphalomesenteric,  origin  of,  78. 

Vense  cavae,  fetal,  81. 

Ventricles,    fetal,    81. 

Ventrofixation,  and  ventrosuspension  of 
uterus,  followed  by  pregnancy  and  labor, 
600-602. 

Vernix  caseosa,  origin  of,   85;    removal  of, 

785. 

Version,  919—936;  classification  of,  919; 
combined  or  bipolar  podalic,  925-929, 
in  cephalic  presentation,  927,  928,  in 
shoulder  presentation,  925,  926;  def- 
inition of,  919;  in  breech  presentation, 
537;  in  brow  presentation,  508;  in- 
dications for,  919;  in  cancer  of  uterus, 
610;  in  case  of  monsters,  561;  in 
face  presentation,  518;  in  impacted 
shoulder  presentation,  935;  internal 
cephalic,  924;  internal  podalic,  929- 
936;  in  pelvic  deformity,  658, 
664;  in  pelvic  presentation,  537;  in 
persistent  occipito-posterior  position, 
549;  in  placenta  prasvia,  223;  in 
pregnancy,  537;  in  prolapse  of  arms, 
521;  in  prolapse  of  umbilical  cord,  527; 
in  rupture  of  uterus,  589,  590;  in  shoul- 
der presentation,  544;  pelvic,  936; 
posture  in,  921,  922;  podalic,  925-936; 
prognosis  of,  936;  sling  in,  935,  936; 
spontaneous,  in  shoulder  presentation, 
541;    varieties  of,   919,   920. 

Vertex  presentation,  450-463;  diagnosis  of, 
461,  462,  after  labor,  462;  etiology  of, 
423,  424;  frequency  of,  423;  causes  of 
frequency  of,  423,  424;  prognosis  of,  462. 

Vertigo  in  pregnancy,  334. 

Vesical,  calculus  in  pregnancy,  318,  cause 
of  dystocia,  615;  hemorrhoids  in  preg- 
nancy, 318;  irritation  in  pregnancy, 
316;  neoplasms  and  traumatisms  in 
pregnancy.  319. 

Vesicle,  blastodermic,  64;  chorionic,  44; 
umbilical,  71. 

Vicarious  menstruation,    24. 

Vienna  method  of  internal  cephalic  version, 
24. 


Villi,  anchoring,  70;  chorionic,  44,  descrip- 
tion of,  69,  70;    degeneration  of,  198. 

Virginity,  signs  of,  30. 

Vision,  disturbances  of,  in  pregnancy,  1 16. 

Vitelline,  stalk,  57;   veins,  origin  of,  78. 

Vitellus,  41,  42. 

Vomiting,  benign,  300 ;  in  hydatidiform  mole, 
200,  299;  in  newly  born,  852;  in  preg- 
nancy, 115,  physiological,  299;  in 
phlegmasia  alba  dolens,  736,  737;  perni- 
cious, in  labor,  669,  in  pregnancy,  300- 
303,  diagnosis  of,  301,  due  to  metritis, 
282,  due  to  toxemia,  300,  etiology  of, 
300,  prognosis  of,  301,  symptoms  of, 
300-303  treatment  of,  300,  301,  types 
of,  300. 

Vulva,  atresia  of,  287;  bacteriology  of,  149, 
716;  changes  in,  in  pregnancy,  125; 
condition  of,  in  menstruation,  21; 
hematoma  of,  in  pregnancy,  291,  613; 
oedema  of,  in  pregnancy,  290,  291; 
pruritus  of,  in  pregnancy,  323;  rigidity 
of,  cause  of  dystocia,  612. 

Vulval,  douche,  881;  dressing,  490,  496,  690; 
lacerations,  597-599. 


W, 

Walcher's  position,  379,  387,  870,  871,  975; 

in  forceps  delivery,    879;   in  labor,  876; 

in    pelvic    application    of  forceps,    998; 

in  pelvic  deformity,  657. 
Walcher-Trendelenburg  posture,  875. 
Waters,  bag  of,  at  birth,  66. 
Weaning,  796. 
Weight,  fetal,  86,  87,  419,  784;  of  newly  born, 

784;  in  puerperium,  677;   placental  and 

fetal,   comparison  of,   222. 
Wet-nurse,  788. 

Wharton's  jelly,  73;   formation  of,  85. 
White  infarcts  of  placenta,  234. 
Widal  reaction  with  fetal  blood,  257. 
Wigand-Martin  method  in  breech  presenta- 
tion, 978,  980. 
Winters',  formulae  for  home  modification  of 

milk,    791;    tabular  guide   for  artificial 

feeding,  792. 
Wolffian,  body,     formation    of,     60;      duct, 

formation  of,   60. 
Wounds,  fetal,   269;    penetrating,  of  gravid 

uterus,  370. 
Wry  neck,  traumatic,  832. 


Yellow  fever,  in   pregnancy,   258;    of  fetus, 

25S. 
Yolk   sac,    64;     mammalian,    57;     origin   of, 

63. 


Zona,  pellucida,  43;    radiata,  43. 
Zoosperm,  maturation  of,  44;    origin  of,  60. 


Appendix  (1039-1046) 

Card  index  case  for  obstetrical  histories,  1039.  '    History  cards,  method  of  using,  1039-1042. 

Cards  for  history  records,  1040.  History  records,  1039-1042;  in  private  prac- 

Chart  for  institutional  and  educational  work,  tice,  1039-1040. 
1039-1042. 


^^^^ 


i^mQx 


